Use of ultrarapid acting insulin

ABSTRACT

Disclosed herein are improved methods of treating hyperglycemia with a combination of an ultrarapid acting insulin and insulin glargine comprising prandial administration of the ultrarapid insulin, and administration of a first dose of insulin glargine within 6 hours of waking for a day.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.15/421,743, filed Feb. 1, 2017, which is a continuation of U.S. patentapplication Ser. No. 13/357,821, filed Jan. 25, 2012, which is acontinuation of U.S. patent application Ser. No. 12/539,499, filed Aug.11, 2009, which claims benefit of priority under 35 U.S.C. § 119(e) fromU.S. Provisional Patent Application Ser. No. 61/087,943 filed Aug. 11,2008, 61/097,495 and 61/097,516 filed Sep. 16, 2008, and 61/138,863filed Dec. 18, 2008, the contents of each of these applications areincorporated herein by reference in their entirety.

FIELD OF THE INVENTION

The present invention relates to methods for treating diabetes mellituswith an ultrarapid acting prandial insulin. Particular embodiments ofthe invention relate to various modes of administration which takeadvantage of the unique kinetic profile of such formulations, as well assubstitution of such an insulin for one or more oral antidiabetic agentsin the standard treatment regimen of diabetes mellitus, type 2.

BACKGROUND OF THE INVENTION

Diabetes mellitus (hereinafter, diabetes) currently afflicts at least200 million people worldwide. The two main sub-types of diabetes includetypes 1 and 2. Type 1 diabetes accounts for about 10% of the 200 millionafflicted with diabetes. Type 1 diabetes is caused by autoimmunedestruction of insulin-secreting β-cells in the pancreatic islets ofLangerhans. Type 2 diabetes accounts for the remaining 90% ofindividuals afflicted, and the prevalence is increasing. Type 2 diabetesis often, but not always, associated with obesity, and althoughpreviously termed late-onset or adult-onset diabetes, is now becomingincreasingly more prevalent in younger individuals. Type 2 diabetes iscaused by a combination of insulin resistance and inadequate insulinsecretion.

The Physiological Role of Insulin

In a non-stressed normal individual, the basal glucose level will tendto remain the same from day to day because of an intrinsic feedbackloop. Any tendency for the plasma glucose concentration to increase iscounterbalanced by an increase in insulin secretion and a suppression ofglucagon secretion, which regulate hepatic glucose production(gluconeogenesis and release from glycogen stores) and tissue glucoseuptake to keep the plasma glucose concentration constant. If theindividual gains weight or becomes insulin resistant for any otherreason, blood glucose levels will increase, resulting in increasedinsulin secretion to compensate for the insulin resistance. Thereforethe glucose and insulin levels are modulated to minimize changes inthese concentrations while relatively normal production and utilizationof glucose are maintained.

Five different phases of insulin secretion have been identified: (1)basal insulin secretion wherein insulin is released in thepostabsorptive state; (2) the cephalic phase wherein insulin secretionis triggered by the sight, smell and taste of food, before any nutrientis absorbed by the gut, mediated by pancreatic innervation; (3)early-phase insulin secretion wherein an initial burst of insulin isreleased within the first 5-10 minutes after the β-cell is exposed to arapid increase in glucose, or other secretagogues; (4) second-phaseinsulin secretion wherein the insulin levels rise more gradually and arerelated to the degree and duration of the stimulus; and (5) athird-phase of insulin secretion that has only been described in vitro.During these stages, insulin is secreted, like many other hormones, in apulsatile fashion, resulting in oscillatory concentrations in the blood.Oscillations include rapid pulses (occurring every 8-15 minutes)superimposed on slower oscillations (occurring every 80-120 minutes)that are related to fluctuations in blood glucose concentration.

Insulin secretion can be induced by other energetic substrates besidesglucose (particularly amino acids) as well as by hormones and drugs. Ofnote is that the insulin response observed after food ingestion cannotbe accounted for solely by the increase in blood glucose levels, butalso depends on other factors such as the presence of free fatty acidsand other secretagogues in the meal, the neurally activated cephalicphase and gastrointestinal hormones.

When an individual is given an intravenous glucose challenge, a biphasicinsulin response is seen which includes a rapid increase with a peak, aninterpeak nadir and a subsequent slower increasing phase. This biphasicresponse is only seen when glucose concentration increases rapidly, suchas after a glucose bolus or glucose infusion. A slower increase inglucose administration, what is seen under physiologic conditions,induces a more gradually increasing insulin secretion without thewell-defined biphasic response seen in response to bolus infusion ofglucose.

Modeling of early-phase insulin responses under normal physiologicconditions has demonstrated that, after a meal, glucose concentrationincreases more gradually (C_(max) reached in approximately 20 minutes)than seen with intravenous bolus injections of glucose (C_(max) reachedin approximately 3-10 minutes).

Healthy pancreatic β-cells generate an early response to a meal-likeglucose exposure that rapidly elevates serum insulin both in the portalcirculation and in the periphery. Conversely, defective β-cells, whichhave an impaired early-phase insulin response, generate a sluggishresponse to the meal-like glucose exposure.

Increasingly, evidence indicates that an early relatively rapid insulinresponse following glucose ingestion plays a critical role in themaintenance of postprandial glucose homeostasis. An early surge ininsulin concentration can limit initial glucose excursions, mainlythrough the inhibition of endogenous glucose production. Therefore theinduction of a rapid insulin response in a diabetic individual isexpected to produce improved blood glucose homeostasis.

In a normal individual, a meal induces the secretion of a burst ofinsulin, generating a relatively rapid spike in serum insulinconcentration that then decays relatively quickly (see FIG. 1). Thisearly-phase insulin response is responsible for the shut-off, orreduction, of glucose release from the liver. Homeostatic mechanismsthen match insulin secretion (and serum insulin levels) to the glucoseload. This is observed as a slow decay of modestly elevated seruminsulin levels back to baseline and is second-phase kinetics.

Diabetes

A central characteristic of diabetes is impaired β-cell function. Oneabnormality that occurs early in the disease progression in both type 1and 2 diabetes is the loss of eating-induced rapid insulin response.Consequently, the liver continues to produce glucose, which adds to theglucose that is ingested and absorbed from the basic components of ameal.

Type 2 diabetics typically exhibit a delayed response to increases inblood glucose levels. While normal individuals usually begin to releaseinsulin within 2-3 minutes following the consumption of food, type 2diabetics may not secrete endogenous insulin until blood glucose beginsto rise, and then with second-phase kinetics, that is a slow rise to anextended plateau in concentration. As a result, endogenous glucoseproduction is not shut off and continues after consumption and thepatient experiences hyperglycemia (elevated blood glucose levels).Another characteristic of type 2 diabetes is impaired insulin action,termed insulin resistance. Insulin resistance manifests itself as both areduced maximal glucose elimination rate (GERmax) and an increasedinsulin concentration required to attain GERmax. Thus, to handle a givenglucose load more insulin is required and that increased insulinconcentration must be maintained for a longer period of time.Consequently, the diabetic patient is also exposed to elevated glucoseconcentrations for prolonged periods of time, which further exacerbatesinsulin resistance. Additionally, prolonged elevated blood glucoselevels are themselves toxic to β cells.

Type 1 diabetes occurs as a result of the destruction of theinsulin-producing cells of the pancreas (β-cells) by the body's ownimmune system. This ultimately results in a complete insulin hormonedeficiency. Type 2 diabetes arises from different and less wellunderstood circumstances. The early loss of early phase insulin release,and consequent continual glucose release, contributes to elevatedglucose concentrations. High glucose levels promote insulin resistance,and insulin resistance generates prolonged elevations of serum glucoseconcentration. This situation can lead to a self-amplifying cycle inwhich ever greater concentrations of insulin are less effective atcontrolling blood glucose levels. Moreover, as noted above, elevatedglucose levels are toxic to the β-cells, reducing the number offunctional β-cells. Genetic defects impairing the growth or maintenanceof the microvasculature nourishing the islets can also play a role intheir deterioration (Clee, S. M., et al. Nature Genetics 38:688-693,2006). Eventually, the pancreas becomes overwhelmed, and individualsprogress to develop insulin deficiency similar to people with type 1diabetes.

Therapy

Insulin therapy is the standard treatment for type 1 diabetes. Whileincipient type 2 diabetes can be treated with diet and exercise, mostearly stage type 2 diabetics are currently treated with oralantidiabetic agents, but with limited success. Patients generallytransition to insulin therapy as the disease progresses. Thesetreatments, however, do not represent a cure.

In a typical progression the first oral antidiabetic agent used ismetformin, a suppressor of hepatic glucose output. Use of metformin isnot associated with weight gain or hypoglycemia. If metformin treatmentis insufficient to control hyperglycemia, an insulin secretagogue, mosttypically a sulfonylurea, can be added to the treatment regimen.Secretagogues raise the basal level of insulin in order to lower averageblood glucose levels. Use of sulphonylureas is associated with weightgain and can lead to hypoglycemia, although severe hypoglycemia isinfrequent. If this combination of two oral antidiabetic agents isinadequate to control hyperglycemia either a third oral agent, such as aglitazone, or a long-acting, basal insulin can be added to the regimen.As the disease progresses, insulin therapy can be intensified by theaddition of intermediate and short (rapid) acting insulin preparationsadministered in association with at least some of the day's meals.

Current insulin therapy modalities can supplement or replaceendogenously-produced insulin to provide basal and second-phase-likeprofiles but do not mimic early-phase kinetics (see FIG. 2).Additionally, conventional insulin therapy often involves only one ortwo daily injections of insulin. However, more intensive therapy such asthree or more administrations a day, providing better control of bloodglucose levels, are clearly beneficial (see for example Nathan, D. M.,et al., N Engl J Med 353:2643-53, 2005), but many patients are reluctantto accept the additional injections. Use of these conventional insulinpreparations is associated with weight gain and a significant risk ofhypoglycemia including severe, life-threatening hypoglycemic events.

Until recently, subcutaneous (SC) injection has been the only route ofdelivering insulin for self-administration by patients commerciallyavailable. However, SC insulin administration does not lead to optimalpharmacodynamics for the administered insulin. Absorption into the blood(even with rapid acting insulin analogues) does not mimic the prandialphysiologic insulin secretion pattern of a rapid spike in serum insulinconcentration. Subcutaneous injections are also rarely ideal inproviding insulin to type 2 diabetics and may actually worsen insulinaction because of delayed, variable and slow rate of absorption into thebloodstream. It has been shown, however, that if insulin is administeredintravenously with a meal, early stage type 2 diabetics experience theshutdown of hepatic glucose release and exhibit increased physiologicglucose control. In addition their free fatty acids levels fall at afaster rate than without insulin therapy. While possibly effective intreating type 2 diabetes, intravenous administration of insulin is not areasonable solution, as it is not safe or feasible for patients tointravenously administer insulin at every meal.

For a short period of time there was an inhalable insulin, EXUBERA®(Pfizer), which was marketed for the treatment of diabetes. This insulinpreparation had a pharmacokinetic profile similar to the injectablerapid acting analogues and was used as a substitute for short actinginsulin in the standard treatment paradigm. While this insulinpreparation did allow patients using short acting insulins to avoidinjections, it offered no other notable advantage which contributed toits commercial failure. Moreover, because its kinetic profile was sosimilar to subcutaneously administered regular and rapid-actinginsulins, that after accounting for differences in bioavailability, itsdosing and modes of administration could generally follow that of thosesubcutaneous insulins.

Though not yet commercially available, an ultrarapid acting insulin,insulin-fumaryl diketopiperazine (FDKP) has been under development.Growing experience with the use of this insulin formulation in humanstudies is showing that its unique kinetic profile can accommodatedifferent dosing schemes and modes of administration as its use isapplied to various situations and patient populations in order toachieve improved glycemic control. Such methods are the object of thepresent disclosure.

SUMMARY OF THE INVENTION

Embodiments disclosed herein include methods useful for treatingdiabetes mellitus including both type 1 and type 2 using an ultrarapidacting insulin formulation. The disclosed methods relate to proceduresfor determining dosages, the use of standard dosages that are notadjusted from individual meal to meal, the use of split dosages whereinthe insulin formulation is administered at the beginning of the meal andat a subsequent point in time. In certain embodiments, the insulinformulation is insulin-FDKP and is administered by pulmonary inhalation.Such formulations can be advantageously used in the treatment ofpatients with subcutaneous insulin resistance, and methods of selectingsuch patients are also disclosed herein.

Embodiments of the method include administration of insulin in a mannerthat mimics the meal-related early phase insulin response. In mimickingearly phase kinetics peak serum insulin levels can be reached withinabout 12 to within about 30 minutes of administration. Serum insulinlevels can also return to approach baseline within about two or threehours of administration. Insulin preparations mimicking early phasekinetics in this manner are referred to herein as ultrarapid actinginsulins. In one embodiment a dose sufficient to reduce or controlglucose excursions is used. In one embodiment, insulin is administeredto a patient in need of insulin therapy at mealtime, that is, withinabout 10 minutes, preferably 5 minutes before, or 30, 25, 15, or 10minutes after starting a meal. (The shorter times after starting beingpreferred for patients with normal gastric emptying, the longer timesafter starting being appropriate for patients with delayed gastricemptying). In further embodiments, insulin is administered at leasttwice, initially at the beginning of the meal (that is within 10 minutesplus or minus of starting a meal) and a second time such as 30-120minutes after beginning the meal.

In preferred embodiments, a pulmonary delivery is achieved by inhalationof a dry powder formulation comprising fumaryl diketopiperazine (FDKP)associated with insulin. In such usage the term “fumaryldiketopiperazine” as used herein also includes the salts thereof. Onesuch embodiment comprises insulin and an FDKP salt. In another suchembodiment insulin is complexed with FDKP. For example insulin may becomplexed (bound) to the surface of self-assembled crystalline FDKPmicroparticles, referred to herein generically as “insulin-FDKP”, butalso as TECHNOSPHERE® insulin (TI, MannKind Corp.). In otherembodiments, FDKP is replaced by other C-substituted diketopiperazines,for example 3,6-di(succinyl-4-aminobutyl)-2,5-diketopiperazine(“succinyl diketopiperazine”, SDKP). In an aspect of these embodimentsdelivery is facilitated by use of a unit dose inhaler such as theMEDTONE® inhaler system (MannKind Corp.) utilized in the examples belowand described in U.S. Pat. Nos. 7,305,986 and 7,464,706 which areincorporated herein by reference in their entirety. Preferred dosages,based on fill for this system, are in the range of about 7.5 IU to 120IU, particularly 15 to 90 IU, or greater than 24 IU of insulin complexedwith fumaryl diketopiperazine, or the equivalent. Dosages can also beexpressed as the dose emitted from the inhaler. These doses arepreferably in the range of 6 U to 48 U per inhaler cartridge for patientdosages of 6 U to 72 or 96 U. As explained below dosages can be moreuniversally expressed in subcutaneous equivalent (subQ eq) units. Inthese units preferred dosages are in the range of 1-32 or more units,for example 3, 6, 9 . . . or 4, 8, 12 . . . subQ eq units. For examplewith an alternative inhaler system as described in U.S. patentapplication Ser. Nos. 12/484,125, 12/484,129, and 12/484,137, dosages of3-4 subQ eq units are obtained with cartridges filled with 20-22 IU.

In an embodiment, the insulin dose comprises a dose sufficient tocontrol glucose excursions. In another embodiment, the insulin reachespeak serum levels within about 15 minutes of administration. In anotherembodiment, the peak serum insulin level is at least 60 mU/L. In stillanother embodiment, the peak serum insulin concentration is at least 60,100, or 120 mU/L above the pre-dosing insulin concentration baseline. Inone aspect of this embodiment, the recipient has type 2 diabetes. Inanother embodiment, the insulin dose is sufficient to control bloodglucose levels. In yet another embodiment, the insulin dose issufficient to reduce or suppress glucose release from the liver. In oneaspect of this embodiment, the suppression lasts several hours (see FIG.5). In one aspect of this embodiment a nadir in endogenous glucoseproduction is reached more quickly than following subcutaneousadministration of regular insulin or a rapid-acting insulin analogue,preferably in 60 minutes, more preferably in ≤50 minutes, still morepreferably in about 40 minutes. In still another embodiment the dose issufficient to maximally suppress endogenous glucose production.

Additional embodiments provide methods for improved treatment ofpatients with diabetes comprising selecting a patient in need ofimproved glycemic control, discontinuing current treatment, androutinely administering an ultrarapid acting insulin with at least twomeals each day.

In other embodiments, the need for improved glycemic control isdetermined from HbA1c levels. In one embodiment, the level of serumHbA1c is ≥8%. In yet other embodiments, the level of serum HbA1c is≥7.5%, ≥7.0%, ≥6.5% or ≥6.0%. In other embodiments, the need forimproved glycemic control is determined from elevated mean amplitude ofglucose excursions or elevated post prandial blood glucose levels. Inyet another embodiment, the patient has evidence of elevated oxidativestress and the oxidative stress is measured by 8-iso PGF(2a) levels.Elevated oxidative stress is correlated with elevated mean amplitude ofglucose excursions.

In one aspect of these embodiments, the patient is further in need ofavoiding weight gain, and treatment with the ultrarapid acting insulindoes not result in weight gain or as much weight gain as expected fromanother mode of treatment. In a related embodiment, the patient is obeseand/or in need of losing weight and treatment with the ultrarapid actinginsulin results in weight loss, stable weight, or less weight gain asexpected from another mode of treatment. Such embodiments can furthercomprise a step for assessing weight loss or less than otherwiseexpected weight gain. In one aspect of the invention the assessment isconducted at ≥12 weeks of treatment with meal-time ultrarapid actinginsulin. In another aspect the assessment is conducted at ≥24 weeks. Inyet other aspects the assessment is conducted at ≥36 week or ≥48 weeks.

In various embodiments, the method further comprises assessment of animprovement in glycemic control. In one embodiment, glycemic control isassessed as HbA1c level. In another embodiment, glycemic control isassessed as postprandial glucose excursion. In one aspect postprandialglucose excursion is assessed as postprandial blood glucose level. Inanother aspect it is assessed as oxidative stress, e.g. as 8-iso PGF(2a)levels or other indicators known in the art. In another embodiment,glycemic control is assessed as fasting blood glucose. In furtherembodiments, these factors are assessed in various combinations. In oneaspect of embodiments, the assessment is conducted at ≥12 weeks oftreatment with meal-time ultrarapid acting insulin. In another aspect,the assessment is conducted at ≥24 weeks. In yet other aspects theassessment is conducted at ≥36 week or ≥48 weeks.

In one embodiment, ultrarapid acting insulin is routinely administeredwith at least two meals each day. In another embodiment, ultrarapidacting insulin is administered with at least three meals each day. Inanother embodiment, ultrarapid acting insulin is administered with eachmain or substantive meal each day. In another embodiment, the ultrarapidacting insulin is administered with any meal containing more than 15 gof carbohydrate.

Some embodiments comprise modifying a current standard of care treatmentregimen for diabetes by substituting prandial administration of anultrarapid acting insulin preparation for one or another of theadvocated treatments.

One embodiment provides methods for more effectively combining anultrarapid acting insulin with a long acting insulin analog, for exampleinsulin glargine. In this embodiment prandial administration of theultrarapid acting insulin is combined with a morning dose of a longacting insulin analog administered within 6 hours of waking for a day.In aspects if this embodiment the long acting insulin analog dose isadministered within 1, 2, 3, or 4 hours of waking. In one aspect of thisembodiment the long acting insulin analog is insulin glargine. Inanother aspect of this embodiment the long acting insulin analog isinsulin detemir. In related aspects the long acting insulin analog isinsulin glargine and a second dose is administered from 8 to 14 hoursafter the morning dose. Alternatively the first dose is the only doseadministered in the course of the day. In still another embodimentinstead of using injections of a long acting insulin, an insulin pump isused to provide a continuous infusion of an insulin, for example regularhuman insulin. In one embodiment the ultrarapid acting insulinformulation comprises insulin and a diketopiperazine. In a particularembodiment the ultrarapid acting insulin formulation comprisesinsulin-FDKP.

Some embodiments comprise modifying a current standard of care treatmentregimen for type 2 diabetes by substituting prandial administration ofan ultrarapid acting insulin for treatment with an insulin secretagogue.Other embodiments comprise modifying a current standard of caretreatment regimen for type 2 diabetes by substituting prandialadministration of an ultrarapid acting insulin for treatment with aninsulin sensitizer. Still other embodiments comprise modifying a currentstandard of care treatment regimen for type 2 diabetes by substitutingprandial administration of an ultrarapid acting insulin for treatmentwith both an insulin secretagogue and an insulin sensitizer.

In one embodiment disclosed herein, a method is provided for treatingdiabetes type 2, comprising: selecting a patient with diabetes type 2currently being treated with a suppressor of hepatic glucose output andan insulin secretagogue; discontinuing treatment with the insulinsecretagogue; and routinely administering an ultrarapid acting insulinpreparation with at least one established meal. In another embodiment,treatment with the suppressor of hepatic glucose output is alsodiscontinued.

In another embodiment, the patient is further selected for having aninsulin resistance at the lower portion of the insulin resistancespectrum. In yet another embodiment, the patient is further selected forneeding to reduce or avoid weight gain. In yet another embodiment, thepatient is further selected for having well or moderately controlledfasting blood glucose. In yet another embodiment, the patient is furtherselected for having an HbA1c level ≥8. In yet another embodiment, thepatient is further selected for having an elevated mean amplitude ofglucose excursions

In yet another embodiment, the administering step does not comprise aninjection and wherein patient is further a candidate for treatment withinsulin and is further selected on the basis of being needle-phobic ordesiring to avoid frequent injections.

In another embodiment, the suppressor of hepatic glucose output ismetformin and the insulin secretagogue is a sulfonylurea. In oneembodiment, the ultrarapid acting insulin preparation is administered byinhalation, such as a dry powder. In another embodiment, the ultrarapidacting insulin preparation comprises a fumaryl diketopiperazine (FDKP)associated with insulin such as insulin-FDKP.

In another embodiment, the ultrarapid acting insulin preparation isadministered with each meal containing more than 15 g of carbohydrate.In another embodiment, ultrarapid acting insulin preparation isadministered at a dosage sufficient to maximally reduce hepatic glucoseoutput within 60 minutes of administration. In another embodiment, theultrarapid acting insulin preparation is administered at a dosage withinthe range of 1 to 32 subcutaneous equivalent units.

In one embodiment, provided herein is a method of treating diabetes type2, comprising: selecting a patient with diabetes type 2 currently beingtreated with a suppressor of hepatic glucose output who is in need ofimproved glycemic control and who would be a candidate for combinationtreatment with said suppressor of hepatic glucose output and an insulinsecretagogue; and instead combining treatment with said suppressor ofhepatic glucose output with routinely administering an ultrarapid actinginsulin preparation with at least one established meal.

In one embodiment provided herein is a method of treating diabetes type2, comprising: selecting a patient with diabetes type 2 currently beingtreated with an insulin sensitizer and an insulin secretagogue;discontinuing treatment with the insulin secretagogue; and routinelyadministering an ultrarapid insulin preparation with each meal. Inanother embodiment, treatment with the insulin sensitizer is alsodiscontinued. In yet another embodiment, the patient is further selectedfor having an insulin resistance at the higher portion of the insulinresistance spectrum. In another embodiment, the insulin sensitizer is athiazolidinedione (TZD) such as pioglitazone.

In one embodiment, provided herein is an improved method of treatinghyperglycemia with a combination of an ultrarapid acting insulin and along acting insulin analog comprising: prandial administration of theultrarapid insulin, and administration of a dose of the long-actinginsulin analog within 6 hours of waking for a day. In anotherembodiment, the hyperglycemia is resultant of diabetes type 2. Inanother embodiment, the administration of the long acting insulin analogis within 3 hours of waking. In another embodiment, the long actinginsulin analog is insulin detemir or insulin glargine. In yet anotherembodiment, the long acting insulin is insulin glargine and the methodfurther comprises administering a second dose of insulin glargine andthe second dose is administered from 8 to 14 hours after said morningdose.

In another embodiment, the ultrarapid acting insulin comprises aformulation comprising insulin and a diketopiperazine, such asinsulin-FDKP. In another embodiment, the ultrarapid acting insulin isadministered by inhalation into the lungs.

In one embodiment, provided herein is an improved method of treatinghyperglycemia with a combination of an ultrarapid acting insulin and anexogenous basal insulin comprising: prandial administration of theultrarapid insulin, and continuous infusion of a short acting insulinwith an insulin pump. In another embodiment, the short-acting insulin isregular human insulin or a rapid acting insulin analog. In anotherembodiment, the ultrarapid-acting insulin formulation is insulin-FDKP.

In one embodiment, provided herein is a method of controlling glycemiarelated to a daily meal without adjusting an insulin dose for mealcontent comprising the step of administering a predetermined dosage ofan ultrarapid acting insulin formulation at mealtime for each dailymeal. In another embodiment, the meal content is ≥25%, ≥50%, ≤150%, or≤200% of a usual meal content as used in determination of thepredetermined dose.

In one embodiment, provided herein is a method of controlling glycemiarelated to a daily meal for a patient with delayed or prolonged nutrientabsorption comprising the steps of: selecting a patient with delayednutrient absorption; administering 50% to 75% of a predetermined dosageof an ultrarapid-acting insulin formulation at mealtime for the dailymeal; and administering the remainder of the predetermined dosage 30 to120 minutes after beginning the daily meal. In another embodiment, theultrarapid acting insulin formulation is insulin-FDKP.

In another embodiment, the delayed nutrient absorption is related to adisease state. In yet another embodiment, the delayed nutrientabsorption is related to a meal content high in fat or fiber. In yetanother embodiment, the prolonged nutrient absorption is related to aprolonged meal.

In one embodiment, provided herein is a method of controlling glycemiarelated to a daily meal wherein insulin dosage is adjusted to theglycemic load of the meal consumed comprising the steps of:administering an initial predetermined dose of an ultrarapid actinginsulin formulation at mealtime for the daily meal; determiningpostprandial blood glucose 1 to 2 hours after beginning the daily meal;and if the postprandial blood glucose is >140 mg/dl administering asecond dose of the ultra rapid acting insulin formulation wherein thesecond dose is 25% to 100% of the initial dose. In another embodiment,the ultrarapid acting insulin formulation is insulin-FDKP.

In one embodiment, provided herein is a method of treating diabeticswith subcutaneous insulin resistance comprising the steps of: selectinga patient with subcutaneous insulin resistance on the basis ofatypically high insulin dosage; discontinuing treatment withsubcutaneously administered rapid-, short-, or intermediate-actinginsulin formulations; and initiating treatment by administration ofprandial doses of insulin-FDKP by inhalation effective for the controlof postprandial hypoglycemia.

In another embodiment, the atypically high insulin dosage is ≥2units/Kg/day. In another embodiment, the selecting step furthercomprises selection of the basis that the patient has normal ornear-normal levels of endogenous basal insulin. In yet anotherembodiment, the level of endogenous basal insulin is ≤50 pU/ml.

In another embodiment, the selecting step further comprises one of thefollowing: selection on the basis of injection site lipoatrophy orlipodystrophy; selection of the basis of the patient having 2 HbA1clevel determinations ≥9% in a 6 to 9 month period while on anintensified insulin regimen; or selection of the basis of the patienthaving life threatening glycemic instability characterized by periods ofhyperglycemia and/or hypoglycemia despite adherence to their insulinregimen and any diet or exercise regimen.

In another embodiment, the method further comprises the step ofconfirming the patient has subcutaneous insulin resistance bydetermining that a similar or improved degree of glycemic control isachieved with a substantially lower dosage of insulin after adjustmentbased on relative bioavailability.

In one embodiment, provided herein is a method for determining anindividual's dosage of an ultrarapid acting insulin for a daily mealcomprising the steps of: administering a low dose of the ultrarapidacting insulin at mealtime for the daily meal for which the dosage isbeing titrated each day for at least 3 days within a titration period ofnot more than a week; iteratively increasing the dosage by the amount ofthe low dose in each subsequent titration period and administering atmealtime for the daily meal for which the dosage is being titrated eachof at least three days in the titration period until a titrationendpoint is reached.

In another embodiment, the low dose is provided in a unit dosecartridge. In another embodiment, titration period is 3 days or oneweek. In another embodiment, the low dose is 1-5 subQ eq units. Inanother embodiment, the ultrarapid acting insulin formulation isinsulin-FDKP.

In another embodiment, the titration endpoint is selected from: 1)achieving a 2-hour post-prandial median glucose is between 70 and 110mg/dl, 2) the dosage based on subcutaneous equivalent (subQ eq) units isa maximal dosage, 3) an episode of severe hypoglycemia with a confirmedSMBG <36 mg/dl occurs and the dosage is decreased by the equivalent ofone low-dose cartridge, and 4) an episode of mild to moderatehypoglycemia with a confirmed SMBG of <70 mg/dl occurs, the dosage isdecreased by the equivalent of one low dose cartridge for one week andthen the titration is resumed until it reaches any of said endpoints 1-3or the dosage is set at the level below that which again produces themild to moderate hypoglycemia.

In another embodiment, the dosages for two or more daily meals aretitrated concurrently. In another embodiment the dosages for two or moredaily meals are titrated successively from the daily meal resulting inthe highest 2-hour postprandial blood glucose to the daily mealresulting in the lowest 2-hour postprandial blood glucose.

In another embodiment, the maximal dosage is 24 subQ eq units or 2 subQeq units.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 depicts the measurement of first-phase insulin release kineticsfollowing artificial stimulation by bolus glucose infusion.

FIG. 2 depicts serum insulin concentration after administration ofsubcutaneous (SC) regular human insulin or SC fast acting insulin(NOVOLOG™) NOVOLOG™ is a registered trademark of Novo NordiskPharmaceuticals, Bagsvaerd, Denmark.

FIG. 3. is a graph of data obtained from a study in which blood glucoseconcentrations were measured at various times after a meal in patientswith type 2 diabetes who were treated with insulin lispro (HUMALOG®, 1),EXUBERA® (2) and an insulin formulation comprising fumaryldiketopiperazine (insulin-FDKP, 3) at the onset of the meal. The graphalso shows (line drawings at its bottom) the exogenous glucose infusionsadministered to the patients as needed to maintain euglycemic levelsfollowing administration of each of the treatments and indicated as 1a,2a and 3a, respectively.

FIG. 4 is a graph of data obtained from a study which measured the rateof absorption of glucose for a period of time after a meal in patientswith type 2 diabetes who were treated with insulin lispro, EXUBERA® andan insulin-FDKP formulation at the onset of the meal.

FIG. 5 is a graph of data obtained from a study in which endogenousglucose production after a meal was determined in patients with type 2diabetes who were treated with insulin lispro, EXUBERA® and aninsulin-FDKP formulation at the onset of the meal.

FIG. 6 is a graph of data obtained from a study which monitored for aperiod of time the rate of glucose disappearance in patients with type 2diabetes, who were treated with insulin lispro, EXUBERA® and aninsulin-FDKP formulation at the onset of the meal.

FIG. 7 depicts the mean insulin concentration-time profiles for patientswith type 2 diabetes who were treated with insulin lispro nd 60 U or 90U of an insulin-FDKP formulation at the onset of the meal from theglucose clamp study.

FIG. 8 depicts the blood glucose concentration of patients with type 2diabetes who were treated with insulin lispro, 3), and 60 U (1) or 90 U(2) of an insulin-FDKP formulation at the onset of the meal from theglucose clamp study. The time of glucose infusion and amount of glucoseinfused is shown as 1a, 2a, and 3a respectively for 60 U and 90 U of aninsulin-FDKP and insulin lispro.

FIG. 9 is a graph of data obtained from a glucose clamp study whichshows the rate of glucose absorption in the patients with type 2diabetes treated with 60 U or 90 U of an insulin-FDKP and insulin lisproimmediately prior to the meal.

FIG. 10 is a graph of data obtained from a glucose clamp experiments inwhich endogenous glucose production after a meal was determined inpatients with type 2 diabetes treated with 60 U or 90 U of aninsulin-FDKP and insulin lispro at the onset of a meal.

FIG. 11 is a graph of data obtained from experiments that monitored therate of glucose disappearance for a period of time in subjects with type2 diabetes treated with 60 U or 90 U of an insulin-FDKP and insulinlispro at the onset of a meal.

FIG. 12 is a graph of data from a study comparing usage of insulin-FDKPand insulin glargine to insulin aspart and insulin glargine presenting7-point blood glucose profiles in the 52^(nd) week of the study.

FIG. 13 is a graph depicting data from experiments measuring fastingblood glucose levels in blood samples from subjects treated withsubcutaneous injections of a basal insulin (insulin glargine/LANTUS®) atbedtime, and insulin-FDKP administered prandially by pulmonaryinhalation. The graph also shows data of a comparison group, i.e.,subjects treated with NOVOLOG® mix 70/30 (premix) at breakfast anddinner as recommended by the manufacturer. The subjects were alldiagnosed as patients with suboptimally controlled type 2 diabetes, whohad been previously treated with regimens of subcutaneous insulins withor without anti-hyperglycemic agents.

FIG. 14 is a graph depicting data from experiments measuring mean bloodglucose levels from samples taken at seven points during the day, i.e.,fasting, post-breakfast, pre-lunch, post-lunch, pre-dinner, post-dinnerand bedtime for three days during the indicated week, in subjectstreated with insulin glargine at bedtime and prandial insulin-FDKP bypulmonary inhalation at the first week of treatment, (hatched lines;baseline) and during the 52nd week (solid line) of treatment. The datashow a rise in blood glucose concentration in subjects with type 2diabetes throughout the day, however, at 52 weeks, the data indicatethat the blood glucose levels were significantly lower that at the onsetof the treatments and better controlled.

FIG. 15 depicts the trial design of a clinical study comparing prandialTI (insulin-FDKP) (Group 1) with metformin+a secretagogue (Group 2) andprandial TI+metformin (Group 3).

FIG. 16 depicts the baseline demographics of patients enrolled in thestudy of FIG. 15.

FIG. 17 depicts lowering of HbA1c at 12 and 24 weeks after treatmentwith TI alone, TI and metformin, or metformin and a secretagogue. Theterms “stayed,” “transferred,” “non-transferred,” and “all transferred”are defined in FIG. 15.

FIG. 18 depicts the proportion of patients reaching their HbA1c goal of≤7% at 12 and 24 weeks after treatment with TI alone, TI and metformin,or metformin and a secretagogue.

FIG. 19 depicts the proportion of patients reaching their HbA1c goal of≤6.5% at 12 and 24 weeks after treatment with TI alone, TI andmetformin, or metformin and a secretagogue.

FIG. 20 depicts blood glucose levels after 12 and 24 weeks of treatmentwith TI alone.

FIG. 21 depicts blood glucose levels after 12 and 24 weeks of treatmentwith metformin and a secretagogue.

FIG. 22 depicts blood glucose levels after 12 and 24 weeks of treatmentwith TI and metformin.

FIG. 23 depicts 1- and 2-hour postprandial blood glucose levels after 12and 24 weeks of treatment with TI alone.

FIG. 24 depicts 1- and 2-hour postprandial blood glucose levels after 12and 24 weeks of treatment with metformin and a secretagogue.

FIG. 25 depicts 1- and 2-hour postprandial blood glucose levels after 12and 24 weeks of treatment with TI and metformin.

FIG. 26 depicts changes in postprandial glucose excursions (measured aschange in AUC levels (mg·hr/dL) after 12 and 24 weeks of treatment withmetformin and a secretagogue.

FIG. 27 depicts fasting blood glucose levels at 12 and 24 weeks aftertreatment with TI alone, TI and metformin, or metformin and asecretagogue.

FIG. 28 depicts changes in weight at 12 and 24 weeks after treatmentwith TI alone, TI and metformin, or metformin and a secretagogue

DEFINITION OF TERMS

Prior to setting forth the detailed disclosure, it may be helpful toprovide an understanding of certain terms that will be used hereinafter:

Dry powder: As used herein “dry powder” refers to a fine particulatecomposition that is not suspended or dissolved in a propellant, carrier,or other liquid. It is not meant to imply a complete absence of allwater molecules.

First-Phase: As used herein, “first-phase” refers to the spike ininsulin levels as induced by a bolus intravenous injection of glucose. Afirst-phase insulin release generates a spike in blood insulinconcentration that is a rapid peak which then decays relatively quickly.

Early phase: As used herein “early phase” refers to the rise in bloodinsulin concentration induced in response to a meal which peaks within20-30 minutes. The distinction between early phase and first phase isnot always carefully adhered to in the general literature.

Excursion: As used herein, “excursion” refers to blood glucoseconcentrations that fall either above or below a pre-meal baseline orother starting point. Excursions are generally expressed as the areaunder the curve (AUC) of a plot of blood glucose over time. AUC can beexpressed in a variety of ways. In some instances there will be both afall below and rise above baseline creating a positive and negativearea. Some calculations will subtract the negative AUC from thepositive, while others will add their absolute values. The positive andnegative AUCs can also be considered separately. More sophisticatedstatistical evaluations can also be used. In some instances it can alsorefer to blood glucose concentrations that rise or fall outside a normalrange. A normal blood glucose concentration is usually between 70 and110 mg/dL from a fasting individual, less than 120 mg/dL two hours aftereating a meal, and less than 180 mg/dL after eating.

Glucose elimination rate: As used herein, “glucose elimination rate”(GER) is the rate at which glucose disappears from the blood. Using aglucose clamp it can be determined as the glucose infusion rate requiredto maintain stable blood glucose, often around 120 mg/dL during aglucose clamp experimental procedure. This glucose elimination rate isequal to the glucose infusion rate, abbreviated as GIR.

Honeymoon phase: As used herein, the “honeymoon phase” of type 1diabetes refers to the early stages of the disease characterized by lossof early phase insulin release and the remaining β-cell functionproduces some insulin, which is released with second-phase kinetics.

Hyperglycemia: As used herein, “hyperglycemia” is a higher than normalfasting blood glucose concentration, usually 126 mg/dL or higher. Insome studies hyperglycemic episodes were defined as blood glucoseconcentrations exceeding 280 mg/dL (15.6 mM).

Hypoglycemia: As used herein, “hypoglycemia” is a lower than normalblood glucose concentration, usually less than 63 mg/dL (3.5 mM).Clinically relevant hypoglycemia is defined as blood glucoseconcentration below 63 mg/dL or causing patient symptoms such ascognitive impairment, behavioral changes, pallor, diaphoresis hypotonia,flush and weakness that are recognized symptoms of hypoglycemia and thatdisappear with appropriate caloric intake. Severe hypoglycemia isdefined as a hypoglycemic episode that required glucagon injections,glucose infusions, or help by another party.

In proximity: As used herein, “in proximity,” as used in relation to ameal, refers to a period near in time to the beginning of a meal.

Insulin composition: As used herein, “insulin composition” refers to anyform of insulin suitable for administration to a mammal and includesinsulin isolated from mammals, recombinant insulin, insulin associatedor derivatized with other molecules, and insulin molecules with alteredsequences, so long as they retain clinically relevant blood glucoselowering activity. Also included are compositions of insulin suitablefor administration by any route including pulmonary, subcutaneous,nasal, oral, buccal and sublingual. Insulin compositions can beformulated as dry powders, aqueous solutions or suspensions, ornon-aqueous solutions or suspensions (as is typical for metered doseinhalers) for inhalation; aqueous solutions or suspensions forsubcutaneous, sublingual, buccal, nasal or oral administration; andsolid dosage forms for oral and sublingual administration.

Insulin-related disorder: As used herein, “insulin-related disorders”refers to disorders involving production, regulation, metabolism, andaction of insulin in a mammal. Insulin-related disorders include, butare not limited to, pre-diabetes, type 1 diabetes mellitus, type 2diabetes mellitus, hypoglycemia, hyperglycemia, insulin resistance,secretory dysfunction, loss of pancreatic β-cell function, and loss ofpancreatic β-cells.

Non-insulin dependent patients having insulin-related disorders: As usedherein “non-insulin dependent patients having insulin-related disorders”refers to patients with disorders for which therapy withexogenously-provided insulin is not the current standard treatment upondiagnosis. Non-insulin dependent patients having insulin-relateddisorders which are not treated with exogenously-administered insulininclude early type 2 diabetes, type 1 diabetes in the honeymoon phase,pre-diabetes and insulin-producing cell transplant recipients.

Insulin resistance: As used herein, the term “insulin resistance” refersto the inability of a patient's cells to respond to insulinappropriately or efficiently. The pancreas responds to this problem atthe cellular level by producing more insulin. Eventually, the pancreascannot keep up with the body's need for insulin and excess glucosebuilds up in the bloodstream. Patients with insulin resistance oftenhave high levels of blood glucose and high levels of insulin circulatingin their blood at the same time.

Insulin resistance spectrum: As used herein “insulin resistancespectrum” refers to the range over which the degree to which a patientis resistant to insulin can vary. It is well understood that from personto person, and from one point in the progression of type 2 diabetes toanother the degree of insulin resistance can differ. Although there areno generally accepted units of insulin resistance it is well within theability of one of ordinary skill in the art to recognize a lower degreeof insulin resistance as opposed to a higher degree of insulinresistance. Ideally insulin resistance can be measured with euglycemicclamp procedures, but these are not practical for routine use. Simplerassessments include HOMA (see Matthew D R, Hosker J P, Rudenski A S, etal., Homeostasis model assessment: insulin resistance and β-cellfunction from fasting plasma glucose and insulin concentrations in man,Diabetologia 1985; 28:412-419) and the related QUICKI (Katz A, Nambi SS, Mather K, Baron A D, Follmann D A, Sullivan G, Quon M J. Quantitativeinsulin sensitivity check index: a simple, accurate method for assessinginsulin sensitivity in humans. J Clin Endocrinol Metab. 2000 July;85(7):2402-10). Fasting serum insulin levels themselves can also be usedas an indicator of the degree of insulin resistance with concentrationsof 50-100 pmol/L indicating resistance at the lower end of the spectrumand concentrations of 300 pmol/L indicating resistance at the higher endof the spectrum. Finally, for patients already on an insulin treatment,the total daily dose is commonly taken as an indicator of whether thesubject has a high or low degree of insulin resistance.

Intermediate acting insulin: As used herein, “intermediate actinginsulin” or lente insulin, refers to an insulin with an onset of actionusually about two to four hours after injection and peaks four to 12hours after injection, and it keeps working for 10 to 18 hours. Typicalintermediate acting insulins are obtained by mixing regular insulin witha substance that makes the body absorb the insulin more slowly. Anon-limiting example is NPH insulin. Intermediate acting insulin canprovide many of the benefits of long acting insulin.

Long acting insulin: As used herein, the term “long acting insulin”refers to an insulin formulation that starts working within about 1-6hours and provides a continuous level of insulin activity for up to 24hours or more. Long-acting insulin operates at maximum strength afterabout 8-12 hours, sometimes longer. Long-acting insulin is usuallyadministered in the morning or before bed. Non-limiting examples of longacting insulin include, but are not limited to, insulin glargine orinsulin detemir, which are insulin analogs, and ultralente insulin whichis regular human insulin formulated to slow absorption. Long actinginsulin is best suited to provide for basal, as opposed to prandial,insulin requirements.

Meal: As used herein, “meal”, “meals”, and/or “mealtime”, etc. includetraditional meals and meal times; however, these also include theingestion of any sustenance regardless of size and/or timing. As usedherein “established meal” refers specifically to the daily periods ofprimary food consumption such as the usual or traditional three dailymeals. Some diabetics are encouraged to eat four somewhat smaller dailymeals to reduce peak blood glucose levels; such meals are also includedwithin the meaning of the term established meal.

Microparticles: As used herein, the term “microparticles” includesmicrocapsules having an outer shell composed of either adiketopiperazine alone or a combination of a diketopiperazine and one ormore drugs. It also includes microspheres containing drug dispersedthroughout the sphere; particles of irregular shape; and particles inwhich the drug is coated on the surface(s) of the particle or fillsvoids therein.

Prandial: As used herein, “prandial” relates something to a meal or asnack. Depending on context in can refer to a period of time less thanan hour after beginning a meal, or for as long as consumption of foodcontinues.

Periprandial: As used herein, “periprandial” refers to a period of timestarting shortly before and ending shortly after the ingestion of a mealor snack.

Postprandial: As used herein, “postprandial” refers to a period of time,generally an hour or more, after beginning a meal and after ingestion ofa meal is completed. As used herein, late postprandial refers to aperiod of time beyond 2 hours after ingestion of a meal or snack.

Potentiation: Generally, potentiation refers to a condition or actionthat increases the effectiveness or activity of some agent over thelevel that the agent would otherwise attain. Similarly it may referdirectly to the increased effect or activity. As used herein,“potentiation” particularly refers to the ability of elevated bloodinsulin concentrations to boost effectiveness of subsequent insulinlevels to, for example, raise the glucose elimination rate.

Pre-Diabetic: As used herein, the term “pre-diabetic” refers to apatient with impaired fasting glucose impaired glucose tolerance, thatis with a fasting blood glucose level between 100 mg/dL (5.5 mmol/L) and126 mg/dL (7.0 mmol/L), or a 2 hour post-prandial blood glucose levelbetween 140 mg/dL (7.8 mmol/L) and 200 mg/dL (11.1 mmol/L).

Rapid acting insulin: As used herein, the term “rapid acting insulin”refers to an insulin formulation that reaches peak blood concentrationin approximately 45-90 minutes and peak activity approximately one to 3hours after administration. Rapid acting insulin can remain active forabout four to six hours. A non-limiting example of a rapid actinginsulin is the insulin analog insulin lispro)(HUMALOG®. The withdrawnproduct EXUBERA® and the experimental formulation VIAJECT® (BiodelInc.), both based on regular human insulin, have kinetic profilesfalling within this definition.

Second-Phase: As used herein, “second-phase” refers to the non-spikingrelease of insulin in response to elevated blood glucose levels. This isdistinct from “second-phase kinetics” which refers to the slow decay ofmodestly elevated blood insulin levels back to baseline.

Short acting insulin: As used herein the term “short acting insulin”includes regular insulin and the rapid acting preparations, typicallyused around mealtimes.

Snack: As used herein “snack” refers specifically to food consumedbetween established meals.

Suppressor of hepatic glucose output: As used herein, the phrase“suppressor of hepatic glucose output” refers to drugs which suppresshepatic glucose production (hepatic gluconeogenesis, mobilization fromglycogen stores). A non-limiting example of a suppressor of hepaticglucose output is metformin.

TECHNOSPHERE® Insulin: As used herein, “TECHNOSPHERE® Insulin” or “TI”refers to an insulin composition comprising regular human insulin andTECHNOSPHERE® microparticles, a drug delivery system. TECHNOSPHERE®microparticles comprise a diketopiperazine, specifically3,6-di(fumaryl-4-aminobutyl)-2,5-diketopiperazine (fumaryldiketopiperazine, FDKP). Specifically, TECHNOSPHERE® Insulin comprises aFDKP/human insulin composition. TECHNOSPHERE® Insulin is an ultrarapidacting insulin as delivered by pulmonary administration and mimicsphysiologic mealtime early phase insulin release. This formulation isalso referred to generically herein as “insulin-FDKP”. In some contextsthe product is referred to as insulin monomer human [rDNA origin]inhalation powder.

As used herein, “diketopiperazine” or “DKP” includes diketopiperazinesand salts, derivatives, analogs and modifications thereof falling withinthe scope of the general Formula 1, wherein the ring atoms E₁ and E₂ atpositions 1 and 4 are either 0 or N and at least one of the side-chainsR₁ and R₂ located at positions 3 and 6 respectively contains acarboxylic acid (carboxylate) group. Compounds according to Formula 1include, without limitation, diketopiperazines, diketomorpholines anddiketodioxanes and their substitution analogs.

Diketopiperazine microparticles, in addition to making aerodynamicallysuitable microparticles enabling delivery to the deep lung, also rapidlydissolve and release any drug cargo further speeding absorption into thecirculation. Diketopiperazines can be formed into particles thatincorporate a drug or particles onto which a drug can be adsorbed. Thecombination of a drug and a diketopiperazine can impart improved drugstability. These particles can be administered by various routes ofadministration. As dry powders these particles can be delivered byinhalation to specific areas of the respiratory system, depending onparticle size. Additionally, the particles can be made small enough forincorporation into an intravenous suspension dosage form. Oral deliveryis also possible with the particles incorporated into a suspension,tablets or capsules.

In another embodiment of the present invention, the DKP is a derivativeof 3,6-di(4-aminobutyl)-2,5-diketopiperazine, which can be formed by(thermal) condensation of the amino acid lysine. Exemplary derivativesinclude 3,6-di(succinyl-4-aminobutyl)-, 3,6-di(maleyl-4-aminobutyl)-,3,6-di(glutaryl-4-aminobutyl)-, 3,6-di(malonyl-4-aminobutyl)-,3,6-di(oxalyl-4-aminobutyl)-, and3,6-di(fumaryl-4-aminobutyl)-2,5-diketopiperazine. The use of DKPs fordrug delivery is known in the art (see for example U.S. Pat. Nos.5,352,461, 5,503,852, 6,071,497, and 6,331,318, each of which isincorporated herein by reference for all that it teaches regardingdiketopiperazines and diketopiperazine-mediated drug delivery). The useof DKP salts is described in co-pending U.S. patent application Ser. No.11/210,710 filed Aug. 23, 2005, which is hereby incorporated byreference for all it teaches regarding diketopiperazine salts. Pulmonarydrug delivery using DKP microparticles is disclosed in U.S. Pat. No.6,428,771, which is hereby incorporated by reference in its entirety.

TECHNOSPHERE®/Placebo: As used herein, “TECHNOSPHERE®/Placebo” refers toTECHNOSPHERE® particles which are not associated with insulin or otheractive agent.

Tmax: As used herein, the term “Tmax” refers to the time fromadministration for a parameter (such as concentration or activity) toreach its maximum value.

Units of measure: Subcutaneous and intravenous insulin dosages areexpressed in IU which is defined by a standardized biologic measurement.Amounts of insulin formulated with fumaryl diketopiperazine are alsoreported in IU as are measurements of insulin in the blood.TECHNOSPHERE®/Insulin dosages are expressed in arbitrary units (U) whichare numerically equivalent to the amount of insulin formulated in thedosage.

DETAILED DESCRIPTION OF THE INVENTION

Insulin-FDKP was discovered to be an ultrarapid acting insulin capableof mimicking physiologic mealtime early phase insulin release. Inexploring how an insulin preparation with this unique pharmacokineticprofile might be used advantageously in the treatment of type 2diabetes, it has up to now been evaluated in comparison to other insulinpreparations (see for example U.S. patent application Ser. Nos.11/032,278, 11/329,686, 11/278,381, and 11/461,746, each of which arehereby incorporated by reference in their entirety). Embodimentsdisclosed herein are concerned with how specific dosages and modes ofadministration for such insulin preparations can be chosen forindividual patients and applied to various patient populations foradvantageous effect. Certain embodiments are concerned with how suchinsulin preparations can be used in combination with and/or in place oforal antidiabetic medications, particularly insulin sensitizers andinsulin secretagogues, to achieve similar or advantageous effect.Certain other embodiments are concerned with how such insulinpreparations can be used in combination with and/or in place ofexogenously provided basal insulins to achieve similar or advantageouseffect. Similar disclosure is also found in U.S. Provisional patentapplication Nos. 61/087,943, 61/097,495, 61/097,516, and 61/138,863,each of which is incorporated herein by reference in its entirety.

In general, various embodiments involve the use of prandial ultrarapidacting insulin in defined populations. These populations may be referredto as being in need of, capable of benefiting from, or desirous ofreceiving the benefit of one or another or more of the advantagesoffered by the various methods described. Such advantages can beexpressed as receiving or seeking some stated clinical benefit. Suchadvantages can also include elimination or avoidance of variousside-effects, adverse outcomes, contraindications, and the like, orreducing the risk or potential for them to occur. Similarly the methodscan involve a step of selecting a patient on the basis of being part ofone or another of populations. It should be understood that selectingcan comprise a physician or other healthcare professional evaluating apatient in respect to the particular parameters but can also comprise aself-selection by the patient to be treated on the basis of similar dataor in accepting the advice of the physician or other healthcareprofessional. In like manner, administering steps of these methods cancomprise the physical taking of a medicament (or similarly discontinuingtreatment with a medicament) by a patient but can also comprise aphysician or other healthcare professional prescribing or providingother specific instruction to take (or discontinue) a medicament.Further embodiments of the invention include use of ultrarapid actinginsulin preparations, compositions, or formulations for such purposes,and in the manufacture of medicaments for such purposes.

As used herein, mimicking physiologic mealtime early phase insulinrelease (or similar terms) does not necessarily indicate exactreplication of all features of the physiologic response. It can refer toinsulin preparations and methodologies producing a spike or peak ofinsulin concentration in the blood that constitutes both a relativelyquick rise and fall in concentration. In certain embodiments, the riseto peak concentration takes less than 30 minutes, preferably less thanabout 20 minutes or 15 minutes and in further embodiments takes at least5 or at least 10 minutes to peak; for example reaching a peakconcentration in 12-14 minutes or 10-20 minutes, etc., fromadministration or first departure from baseline. In certain embodimentsthe fall from the peak insulin concentration involves descent throughhalf maximal by 80 minutes, alternatively 50 minutes, or alternatively35 minutes after peak. Typically insulin concentration will beapproaching baseline with 2 to 3 hours of administration. This is incontrast to insulin preparations and methods producing a more gradualrise (from 30 minutes to several hours) to the maximal insulinconcentration achieved and a prolonged plateau near maximalconcentrations. The rapid acting analogs (RAA) do show a greater degreeof peaking that regular human insulin, but even the fastest of thecommercially available RAAs, as disclosed in their prescribinginformation, insulin lispro (HUMALOG®) reports a Tmax of 30-90 minutes.For comparison, insulin aspart (NOVOLOG®) reports a median Tmax of 40-50minutes in subjects with type 1 diabetes and insulin glulisine)(APIDRA®reports a median Tmax of 60 and 100 minutes in subjects with type 1 andtype 2 diabetes, respectively with a range of 40-120 minutes in bothpopulations. Moreover the RAAs require approximately 6 hours forconcentration to return to baseline. Mimicking physiologic mealtimeearly phase insulin release can also refer to insulin preparations andmethodologies in which the spike in insulin concentration can bereliably coordinated with the start of a meal. It can also refer to theachievement (and associated methodologies) of a maximal glucoseelimination rate (GERmax) within about 30-90 minutes, preferably around45-60 minutes, after administration. Insulin preparations with suchcharacteristics are referred to herein as ultrarapid acting. Inembodiments of the invention a methodology that mimics early phaserelease is generally also one that can be practiced by diabetics uponthemselves without special medical training, such as training inintravenous injection. Special medical training would not includetraining to use medical devices, such as dry powder inhalers, that areroutinely used by persons who are not trained medical professionals. Insome embodiments ultrarapid acting insulin can be administered withevery ingestion of any sustenance regardless of size and/or timing.Nonetheless it is preferred that insulin be administered only for a mealproviding at least a threshold glycemic load (which can depend on theinsulin dose) so as to avoid a risk of hypoglycemia. Various methods ofassessing glycemic load are known in the art including “carb counting”(calculating/estimating the number of grams of carbohydrate in a meal),the use of bread exchanges, and consideration of the glycemic index ofthe foods to be consumed.

The meaning of ultrarapid can also be understood by further comparisonto other insulin preparations. Regular human insulin preparations forsubcutaneous injection are considered short acting, referring primarilyto their duration of action. Typically they will take at least 1-2 hoursto reach maximal blood insulin concentration and can take 2-4 hours toreach maximal activity. Significant elevation or activity can last foras long as 10-12 hours. Other short acting insulins include the rapidacting insulin analogs such as insulin aspart, insulin glulisine, andinsulin lispro. Because these insulin preparations more readilydissociate from hexamer to monomer upon injection they reach peak bloodconcentrations sooner (30-100 minutes) and consequently also have afaster onset of action than regular human insulin. Insulin preparationsfor pulmonary administration, such as the now withdrawn product EXUBERA®display pharmacodynamics similar to the rapid acting analogs. Acomparison of the pharmacodynamic profiles of several pulmonaryformulations, insulin lispro, and insulin-FDKP has been publishedshowing that insulin-FDKP is distinctly faster in reaching maximalactivity and declines toward baseline sooner (Heinemann et al. Br J DiabDis 4:295-301, 2004). Thus, whereas an ultrarapid acting insulin willhave expended approximately two thirds of its insulin lowering activitywithin 2 hours after administration these other preparations willtypically have expended about a third or less of their insulin loweringactivity in that same time frame. At the other end of the spectrum arethe long acting insulins, such as insulin glargine or insulin detemirwhich ideally provide a constant level of insulin activity over longperiods of time, for example up to 24 hours. These are intended toprovide basal activity and are typically administered once or twice aday. As such the rapidity of onset of action is not a criticalparameter. Finally there are insulin preparations, termed intermediateacting, with durations of action between the short and long actingproducts.

The potentiation of GER contributing to the rapid attainment of GERmaxis understood to depend not only on the rapidity of the rise in insulinconcentration, but also on achieving sufficient peak height. For type 1diabetics this is a peak insulin concentration of at least about 60mU/L, preferably at least about 80 mU/L. For type 2 diabetics theinsulin resistance that is part of the condition can necessitate higherinsulin concentrations; typically at least about 100 mU/L, preferably atleast about 120 mU/L, at least about 140 mU/L, or more, depending on thedegree of resistance. Thus in various embodiments the peak height is atleast 60, 100, or 120 mU/L above the pre-dosing insulin concentrationbaseline. These peak insulin concentrations are substantially higherthan those attained with typical doses of non-spiking insulin productssuch as standard preparations for subcutaneous administration, includingthose termed rapid- or fast-acting, and preparations for non-injectedadministration having similar kinetics that have been described.

The comparatively slow and shallow rise in insulin concentration andprolonged period of action associated with insulin preparations that donot mimic early phase release limits their ability to control glucoseexcursions. The dose that can be given is generally inadequate tocontrol the rise in blood glucose following a meal due to the need toavoid inducing hypoglycemia after the glycemic load from the meal hasbeen abated. These issues are further discussed in co-pending U.S.patent application Ser. No. 11/278,381, which is incorporated herein byreference in its entirety. It is emerging that acute fluctuations inblood glucose concentrations (measured for example as MAGE: meanamplitude of glycemic excursions) have a greater effect than chronichyperglycemia (typically measured as Hb1Ac level) on diabetes-associatedoxidative stress, and thus is an important parameter to control to avoiddiabetic complications attributable to such stress (see Monnier, L., etal. JAMA 295:1681-1687, 2006; and Brownlee, M. & Hirsch, I. JAMA295:1707-1708, which are incorporated herein by reference in theirentirety). It is the applicant's further understanding that a high surgeand rapid rate of change in insulin concentration suppresses glucagonproduction, reducing hepatic glucose release. This results in lessenedglycemic load and consequently lessened demand for insulin and reducedglucose excursion.

Ultrarapid acting insulin is particularly well suited to the control ofpostprandial blood glucose (PPG). (For a review of the significance ofPPG see MannKind Corporation. Postprandial hyperglycemia: Clinicalsignificance, pathogenesis, and treatment. Valencia, Calif.: MannKindCorporation; 2009:1-20). The ultrarapid kinetics not only enable bettermatching of insulin activity to the time when glucose is being absorbedfrom a meal, there is also similarly quicker and advantageously timedsuppression of hepatic glucose output (see Example 1). Thus it addressesboth sources of glucose contributing to postprandial hyperglycemia.Embodiments disclosed herein seek to constrain 1 and 2 hour PPG to ≤140mg/dl, ≤180 mg/dl, or ≤200 mg/dl. Surprisingly, it has also becomeapparent that control of PPG levels has long term beneficial effects onfasting blood glucose levels as well. Through consideration of theseproperties and the data from clinical use presented in the Examplesbelow, it is herein disclosed how ultrarapid acting insulins such asinsulin-FDKP may be advantageously used in particular patientpopulations alone or in combination with standard oral antidiabeticmedications and in contrast to current treatment paradigms.

Treatment of diabetes has traditionally focused on controlling averageblood glucose concentrations, as reflected by Hb1Ac levels. Thepresently disclosed methods are designed to minimize not only Hb1Aclevels (average blood glucose concentration) and attendant glucosetoxicity; but also to control acute fluctuations in glucoseconcentration (glucose excursions). The reduction of glucose excursionsalso relieves the general inflammatory burden and oxidative damage tomicrovasculature resulting from oxidative stress. Thus even for patientsin whom substitution of ultrarapid insulin for one or more oralmedications may result in only similar control of HbA1c levels thetreatment can confer a benefit over treatment with oral medicationsalone. Indeed this is a benefit that is also not attainable by additionof basal insulin to the treatment regimen. Nor can the merely rapidacting insulins be expected to deliver this benefit in full measure,especially as compared to an optimized dose of an ultrarapid actinginsulin.

This benefit is accomplished by routinely administering an insulinpreparation that mimics early phase release, that is an ultrarapidacting insulin preparation, in conjunction with at least one, preferablyat least two or three meals a day, or with every established meal, orwith every meal including snacks. Such treatment should be maintained,in increasing preference and for increasing effectiveness, for anynumber of days, weeks, months, and years, up to the remainder of thepatient's life (or until such time as the underlying insulin-relateddisorder is cured or otherwise alleviated). By routinely it is meantthat the advocated schedule of administration is the ideal and usualusage, but real world practice deviations from this protocol, such asoccasional missed meals or missed doses, do not depart from the scope ofthe claimed invention. In various embodiments insulin is routinelyadministered with any meal or snack that would otherwise cause bloodglucose to exceed 140 mg/dL, or alternatively 180 mg/dl; with any mealor snack constituting 1, 2, 3, or more bread exchanges; with any meal orsnack containing more than about 15, 20, 30, or 45 g of carbohydrate.

Embodiments of the methods disclosed herein include a variety of dosingregimens including, but not limited to, dosing at every meal or snack,dosing at every meal or snack having a carbohydrate content of more than15 g, dosing at every meal or snack having a carbohydrate content ofmore than 30 g, every meal or snack having a carbohydrate content ofmore than 45 g. Dosages and desired insulin composition concentrationsmay vary depending on the particular use envisioned. The determinationof the appropriate dosage or route of administration is generally withinthe skill of an ordinary physician. However physicians are most commonlyfamiliar with liquid formulations of insulin which allow for thecontinuous variation of dose. Insulin-FDKP is supplied as a dry powderin premeasured unit doses. Therefore specific instructions fordetermining the appropriate dosages of insulin-FDKP for an individualare disclosed herein. Furthermore the length of treatment may vary onthe particular use and determination of the length of treatment iswithin the skill of an ordinary physician.

The rapid absorption and lack of a substantial tail in the activityprofile of ultrarapid acting insulin preparations, such as insulin-FDKP,also mean that they pose a reduced potential for inducing hypoglycemiaas compared to other insulins. Snacking to counteract late postprandialhypoglycemia is understood to contribute to the weight gain associatedwith standard insulin therapies. In contrast, use of insulin-FDKP hasbeen associated with a lack of weight gain; indeed weight loss has beenobserved.

Intravenous injection of insulin can effectively replicate the firstphase response and approximate the early phase response, but is not apractical therapy for a lifelong condition requiring multiple dailyadministrations. For these reasons, insulin for intravenous injection isnot contemplated by the term ultrarapid acting insulin preparations asused herein. Traditional subcutaneous injections are absorbed into thebloodstream slowly by comparison, even using fast acting formulations,which still take up to an hour to reach maximal concentration in theblood and have a plateau lasting several hours. Many pulmonaryformulations that have been assessed are equivalent to subcutaneousinsulin in effectiveness and similarly fail to achieve the ultrarapidkinetics needed to mimic early phase release, as defined above.Nonetheless, the potential does exist for truly fast absorption using anon-intravenous based delivery, such as pulmonary and oraladministration or subcutaneous injection of formulations comprisingabsorption promoting excipients. As described herein, pulmonary deliveryusing diketopiperazine-based dry powder formulations have been utilized.

Thus, a preferred embodiment provides a method to achieve the desirableearly phase-like kinetics through pulmonary administration of a drypowder insulin formulation containing insulin complexed todiketopiperazine microparticles. This formulation is rapidly absorbedreaching peak serum levels within about 10 to 15 minutes. This is fastenough to mimic the kinetics of the physiologic meal-related early phaseinsulin response. The short, sharp rise to peak serum insulinconcentration is critical to the rapid suppression of endogenous glucoseproduction and has the additional effect of compressing the bulk ofinsulin action to the peri-prandial time interval, in contrast withslower acting formulations. This reduces the magnitude and duration ofany meal-related excursions from normal glucose levels and associatedglucose toxicity, as well as the risk of post-prandial hypoglycemia.Such improved control of blood glucose levels obtainable with this drypowder insulin is more fully described in co-pending U.S. patentapplication Ser. No. 11/278,381, filed Mar. 31, 2006, which isincorporated herein by reference in its entirety. As disclosed in U.S.application Ser. No. 11/329,686 and noted above, prior high insulinlevels potentiate glucose elimination rate, meaning glucose can beeliminated more quickly if there is a prior high insulin concentrationspike.

Diketopiperazine microparticle drug delivery systems and associatedmethods are described in U.S. Pat. Nos. 5,352,461 and 5,503,852. The useof diketopiperazine and biodegradable polymer microparticles inpulmonary delivery is described in U.S. Pat. Nos. 6,428,771 and6,071,497. Details regarding various aspects of possible formulation andmanufacturing processes can be found in U.S. Pat. Nos. 6,444,226 and6,652,885; in U.S. Pat. No. 6,440,463; in U.S. Provisional PatentApplication Nos. 60/717,524, filed Sep. 14, 2005; and 60/776,605, filedApr. 14, 2006. The properties and design of a preferred breath-powereddry powder inhaler system is disclosed in U.S. patent application Ser.No. 10/655,153. Aspects of treatment using insulin complexed todiketopiperazine microparticles are disclosed in U.S. Pat. No. 6,652,885as well as in co-pending U.S. patent application Ser. No. 11/032,278.Additionally U.S. patent application Ser. No. 11/210,710 discloses theuse of diketopiperazine salts to formulate insulin for both pulmonaryand oral delivery. Each of the patents and patent applications mentionedin this paragraph is herein incorporated by reference in its entirety.

Whether insulin-FDKP or another insulin mimicking early phase release isadministered alone or in conjunction with another agent, such as basalinsulin, a suppressor of hepatic glucose release such as metformin, oran insulin sensitizing medication for example a thiazolidinedione (TZD),the ultrarapid acting insulin is administered in association withestablished meals, at least once and preferably two to four times daily,or more times up to with every meal, depending upon need. In order toachieve the maximum benefit of the treatment, it should be taken over anextended period of time, preferably at least 12 weeks, more preferablyat least 24 weeks still more preferably from about 6 months to about twoyears, and most preferably for the remaining life of the patient oruntil the underlying diabetes is cured.

Current treatment of diabetes generally aims to reduce HbA1c levels to7% or below. HbA1c levels above 8% indicate that patient's currenttherapy should be re-evaluated. It may be desirable to achieve normalHbA1c levels, but with the currently marketed insulin products thiscould only be accomplished at an unacceptable risk of severehypoglycemia. Thus patients with HbA1c levels below 8% would not usuallybe considered candidates for more intensive treatment, that is, fortreatment with insulin especially the current prandial insulins. Eventhose with HbA1c above 8% but not yet receiving basal or mixed insulinwould not be considered to be candidates for treatment with a prandialinsulin regimen. In embodiments disclosed herein the risk ofhypoglycemia is much reduced, in part due to the lack of a tail ofinsulin activity exhibited by ultrarapid acting insulin, and it ispossible to treat patients with HbA1c below 7%. Additionally, benefitcan be expected from lowering blood glucose even at the high end of thenormal range. For example one study showed that the risk ofcardiovascular disease events was 5-8 times higher for individuals withHbA1c>7% as compared to those with HbA1c<5%, Another study showed aprogressive increase in risk of kidney disease as HbA1c went from <6%to >8%. Accordingly, in some embodiments, patients with HbA1c levels≤6.5% or ≤6%, are selected for treatment. While the methods aregenerally discussed in reference to human patients adaptation tonon-human mammals is not beyond the scope of the disclosure or theabilities of one of skill in the related arts.

Determination of Individual Dosage

Insulin-FDKP is a dry powder formulation for inhalation provided incartridges containing a premeasured amount of powder which are insertedinto an inhaler. The insulin is administered by inhaling through theinhaler to deliver the powder into the lungs. Cartridges containingdifferent doses can be provided and an individual dosage can be obtainedeither by using a single cartridge containing the desired dosage or byusing multiple cartridges (one at a time).

The patient can be a diabetic with inadequately controlledhyperglycemia, for example with HbA1c greater than 7%, or one withadequately controlled blood glucose levels but desiring to takeadvantage of other advantages obtainable with ultrarapid acting insulin(for example, weight loss or avoidance of weight gain, reduced risk ofhypoglycemia, reduced glucose excursions, etc.).

Determination of individual dosage starts with identification of thedaily meal (that is breakfast, lunch, dinner, regularly occurring snack,etc.) resulting in the highest 2-hour post-prandial blood glucose levelsusing 7 point SMBG (serum measured blood glucose). One then titrates upthe dosage for that meal. Once an appropriate dosage is established forthat meal the dosage for the daily meal leading to the next highestblood glucose level is titrated, and so on until dosages for all dailymeals have been determined. In one embodiment the initial dosage istaken with the untitrated meals In an alternative embodiment thetitration for all daily meals is carried our concurrently rather thansequentially. Meals for which dose titration is being carried out arepreferably “usual” for the patient in terms of size and food componentcontent with little variation in these parameters.

Titration begins by taking one low-dose cartridge with the meal(s) inquestion. Low dose insulin-FDKP cartridges can provide an emitted doseof, for example, 6 or 12 U of insulin. Most commonly the titration iscarried out with 12 U cartridges but patients with smaller body masses,with lesser degrees of hyperglycemia to control, and/or lower degrees ofinsulin resistance may prefer to start the titration at a lower doseand/or proceed through the titration in smaller increments. For claritythe titration is described below with respect to the 12 U dose but itshould be understood that the titration could similarly be based on a 6U or other low-dose cartridge. Similarly even if titrating based on acartridge that is not the lowest dose available one can use a smallerdose low-dose cartridge to provide the last increment (or decrease) indosage as an alternative to the procedure described below.

One uses the initial dosage for a week. In each subsequent week thedosage for the meal is increased by the dose of the low-dose cartridge(i.e. 12 U) until either 1) the 2-hour post-prandial median glucose isbetween 70 and 110 mg/dl, or 2) the dosage, based on emitted dose, is 72U, or 3) an episode of hypoglycemia occurs. For episodes of mild tomoderate hypoglycemia with confirmed SMBG of <70 mg/dl decrease dosageby one low dose (i.e. 12 U) cartridge and hold at that dose for one weekthen resume the titration. For an episode of severe hypoglycemia withconfirmed SMBG <36 mg/dl decrease dosage by one low dose (i.e. 12 U)cartridge, hold at this new dose, and begin titration for next meal. Inan alternative embodiment a pre-meal blood glucose between 70 and 110mg/dl can also be used as a titration endpoint. In some embodiments thesecond criteria above for terminating dose escalation specifies a higherterminal dose or the criteria is not used at all.

In an alternative embodiment the initial dosage can be estimated basedon relative bioavailability from the dosage of a subcutaneouslyadministered insulin. This becomes important in adapting the titrationscheme to other formulations and inhaler systems than that used in theexamples below. A more universal scale is obtained by identifying dosageaccording to the insulin exposure (that is the AUC of blood insulinconcentration over time). As the titration is described above 12Uemitted corresponds to 3-4 subcutaneous equivalent units (subQ eq). Thusin various embodiments the low dose can be, for example, about 1, 1.5,2, 3, 4, or 5 subQ eq units. The limit for dose escalation can be about18, 24, 32 or more subQ eq units.

The expression of dose in subQ eq units also facilitates migration touse of an ultrarapid acting insulin if the patient is already on aninsulin regimen. If the patient is already on a prandial insulin regimenthey should start with the same subQ eq dose as they are currently usingwhich is then titrated up or down from there basically as describedabove. If the patient is on a regimen with longer acting insulin aloneor a mixture of short and longer acting insulins then 50% of the totaldaily dose should be divided by the number of daily meals and thatamount of ultrarapid acting insulin in sub/Q eq units should be used asthe initial dose in the titration. In the case in which the ultrarapidacting insulin is provided in form that does not allow an exact match tothe current dosage one can round down or round to the nearest (that isup or down) dose of the ultrarapid acting insulin to use as the initialdose. In one embodiment this choice is left to the practitioner, butparticular embodiments specify one or the other choice.

Accordingly, provided herein is a method of determining an individual'sdosage of insulin-FDKP for a daily meal comprising the step ofadministering an initial dosage equivalent to one low-dose cartridgewith the meal each day for a week. In each subsequent week the dosage isincreased by the amount of one low-dose cartridge until a titrationendpoint is reached wherein the titration is selected for the groupof 1) achieving a 2-hour post-prandial median glucose is between 70 (oralternatively 80) and 110 mg/dl, 2) the dosage based on emitted dose is72 U, 3) an episode of severe hypoglycemia with a confirmed SMBG <36mg/dl occurs and the dosage is decreased by the equivalent of onelow-dose cartridge, and 4) an episode of mild to moderate hypoglycemiawith a confirmed SMBG of <70 (or alternatively 80) mg/dl occurs, thedosage is decreased by the equivalent of one low-dose cartridge for oneweek and then the titration is resumed until it reaches one of the otherendpoints or the dosage is set at the level below that which producesthe mild to moderate hypoglycemia.

Embodiments disclosed herein comprise a method in which the dosage foreach daily meal is determined as described above for each of the dailymeals in succession. This embodiment comprises determining which dailymeal results in the highest 2-hour postprandial blood glucose level andtitrating that meal first. In some embodiments this determinationutilizes a 7 point SMBG. The daily meal resulting in the next highest2-hour postprandial blood glucose level is then titrated in turn. Theinitial dosage is administered with each meal not being titrated forwith a dosage has not been determined. In alternative embodimentsdosages for all daily meals are titrated concurrently.

In one embodiment the low-dose cartridge provides an emitted dose of 3-4subQ eq units of insulin. In another embodiment the low-dose cartridgeprovides an emitted dose of 1.5-2 subQ eq units of insulin. In someembodiments the group of titration endpoints further comprises a premealblood glucose level between 70 and 110 mg/dl.

In various alternative embodiments the titration is based on at leastthree consecutive daily measurements as opposed to being carried outdaily over a week as described above, or in a further alternative 3-6daily measurements over the course of a week. In other alternativeembodiments the titration is based on preprandial/pre-bedtime SMBGinstead of 2 hour postprandial SMBG. That is the pre-lunch measurementis used to determine the breakfast dose, the pre-dinner measurement isused to determine the lunch dose, and the pre-bedtime measurement isused to determine the dinner dose.

Use of a Standard Dose

Traditional prandial insulin treatment has involved careful adjustmentof insulin dosage to the expected glycemic load of the individual mealbased on its size and content. The need for this can be avoided, or atleast reduced through the use of an ultrarapid acting insulinformulation. Traditional prandial insulin formulations, whetheradministered by subcutaneous injection/infusion or by inhalation, exerttheir effect on blood glucose level largely by elevating the glucoseelimination rate over a relatively extended period of time. The totalglucose elimination brought about is generally proportional to the doseadministered. In contrast ultrarapid acting insulin formulations exerttheir effect over a relatively constrained period of time and a greaterproportion of their effect on blood glucose level is the result ofrapidly reducing hepatic glucose release to basal levels. The rapid riseof blood insulin level obtained with ultrarapid insulins potentiates arapid rise in glucose elimination activity and also provide a signal tothe liver to reduce glucose release. However the high concentrations ofinsulin achieved to bring about these effects exceed the range in whichglucose elimination rate (GER) is proportional to insulin concentration.Thus while further increasing insulin dosage does lengthen the period oftime over which GER is elevated this is brought about by increasing theperiod of time in which the insulin concentration exceeds the range inwhich GER is proportional to insulin concentration. Therefore totalglucose elimination with ultrarapid acting insulins is much lesssensitive to dose. Moreover insulin concentrations return to baselinelevels sooner after administration so the effect is also constrained intime and homeostatic mechanisms reassert themselves much sooner thanwith the relatively longer acting traditional short-acting formulations,thereby reducing the potential for late postprandial hypoglycemia due tothe activity of the exogenous insulin.

As a result it can be feasible to set a standard dosage for each of thedaily meals and use that dose without regard for variation in caloriccontent or glycemic load from meal to meal. Because so much of the bloodglucose lowering effect is related to reduction of hepatic glucoserelease, effective reduction is achieved without careful matching ofdosage to glycemic or caloric load even if a larger meal than usual isconsumed. Because the elevation of GER is comparatively short-lived andgenerally well-matched in time to the period during which a meal willincrease blood glucose levels there is a low risk of hypoglycemia evenif a smaller meal is consumed. Nonetheless in preferred embodiments thecaloric content and/or glycemic load of the meal is maintained within arange of from 25, 50, or 75% to 125, 150, 200 or 250%, of that of theusual meal (used in determining the standard dose). Since insulinresistance, and therefore responsiveness to insulin, does vary withcircadian cycle it will generally be preferred to set a standard dosefor each daily meal, though as a practical matter the standard dosagedetermined may be the same for different daily meals. This method can beparticularly well-suited to diabetics with significant residual abilityto produce insulin and regulate blood glucose levels, such as type 2diabetics earlier in the progression of the disease.

Accordingly, provided herein are methods for treating diabetes withstandardized doses that are not adjusted based on individual mealcontent. The method comprises prandial administration of a predeterminedstandard dosage of an ultrarapid acting insulin formulation withoutadjustment of the dosage based on meal content. In various embodimentsany or all daily meals are treated according to this method; that is forexample breakfast, or breakfast and lunch, or breakfast and dinner, orbreakfast, lunch, and dinner, etc. In some embodiments a singlepredetermined dosage is used for all meals. Preferred embodimentsutilize predetermined dosages for each daily meal; that is for example,for breakfast, for lunch, for dinner, etc. In some embodiments mealcontent is assessed as caloric content. In other embodiments mealcontent is assessed as glycemic load. In preferred embodiments mealcontent is maintained within a range of from 25, 50, or 75% to 125, 150,200 or 250% of a usual meal used in determining the predeterminedinsulin dosage.

In one embodiment the ultrarapid acting insulin formulation isinsulin-FDKP. In another embodiment the administration is by inhalationinto the lungs.

Use of Split, Supplemental, and Delayed Dosages

With traditional prandial insulin regimens a dosage is selected based onan expectation of how much food will be consumed and then an attempt ismade to conform consumption to the advance expectation. If more food isconsumed, or its proportion of carbohydrate, fiber, and fat differs fromusual or anticipated, it is not possible to improve glycemic control byadministering a secondary dose subsequent to the meal when these factorsare known with greater certainty, because of the delay betweenadministration and onset of action with traditional formulations. Incontrast ultrarapid acting insulin formulations take effect so quicklyit can be advantageous to adjust the dosage of insulin to the meal byadministering a secondary dose subsequent to the meal. Use of splitdosages can be particularly well-suited to diabetics other than type 2diabetics with good endogenous insulin production and only moderateinsulin resistance, for example type 1 diabetics (past the “honeymoon”stage of the disease) and type 2 diabetics later in the progression ofthe disease

In one application of this mode of administration split dosage isapplied to meals in which delayed absorption is expected. The delay canbe due to disease state—long-term diabetes is associated with delayednutrient absorption; or can be due to meal content—higher fat and fibercontent tend to delay food absorption. Use of split dosages can also beadvantageously used in conjunction with multi-course or other prolongedmeals such as at holiday celebrations and banquets. Even if theindividual limits total consumption in accordance with their usual mealsthe fact that consumption extends over a longer than usual period oftime will also lead to a prolongation of nutrient absorption. Splitdoses provide a way to address this prolonged profile of nutrientabsorption. As compared to the dosage of insulin that would be used withthe meal as a single dose one-half to three-quarters, for example twothirds, of the dose is administered at the beginning of the meal and theremainder of the dosage is administered 30 to 120 minutes later.

Accordingly, additional embodiments provide a method of treatingdiabetes comprising selecting a patient expected to have delayednutrient absorption, administering an initial dose of ½ to ¾ of apredetermined dosage of an ultrarapid acting insulin formulation at thebeginning of a meal, and administering the remainder of thepredetermined dosage 30-120 minutes later. In one embodiment the initialdose is ⅔ of the predetermined dosage. In some embodiments delayedadsorption is related to a state of the disease (diabetes). In otherembodiments delayed adsorption is related to meal content. In furtheraspects of these embodiments meal content comprises high fiber content.In other aspects of these embodiments meal content comprises high fatcontent. In a further aspect the high fact content constitutes ≥25%, ofthe meal content. In a further aspect the high fat content constitutes≥35%, of the meal content. In one embodiment the ultrarapid actinginsulin formulation is insulin-FDKP. In another embodiment theadministration is by inhalation into the lungs.

In another application of this mode of administration, split dosage isused to adjust the insulin dosage to the actual glycemic load. Aninitial dose is administered at the beginning of the meal, blood glucoselevel is determined 60 to 120 minutes later, and a secondary orsupplemental dose is administered if blood glucose exceeds 140 mg/dl. Insome embodiments the secondary dosage is equal to 50-100% of the initialdosage. In some embodiments blood glucose is determined by continuousglucose monitoring.

Accordingly, additional embodiments provide a method of treatingdiabetes comprising administering an initial dose of an ultrarapidacting insulin formulation at the beginning of a meal, determining ablood glucose level 60-120 minutes after beginning the meal, and if theblood glucose level exceeds 140 (or alternatively 150) mg/dladministering a second dose of the ultrarapid acting insulin formulationwherein the dosage of the second dose is 25% or 50% to 100% of thedosage of the initial dose. In one embodiment the ultrarapid actinginsulin formulation is insulin-FDKP. In another embodiment theadministration is by inhalation into the lungs.

In a variation on this mode of administration no dose is administered atthe initiation of the meal. Instead administration is delayed forexample until 10, 15, 20, or 30 minutes after beginning the meal. Thisvariation is particularly suitable when delayed nutrient absorption isexpected.

Accordingly, embodiments disclosed herein provide a method of treatingdiabetes comprising administering a dose of an ultrarapid acting insulinformulation subsequent to the beginning of a meal to a patient expectingdelayed nutrient absorption. In one embodiment delayed absorption is dueto higher fat and fiber content as compared to a usual meal as used indetermining dosage. In another embodiment delayed absorption is due tolong standing diabetes. In one embodiment the ultrarapid acting insulinformulation is insulin-FDKP. In another embodiment the administration isby inhalation into the lungs.

Treatment of Patients of with Subcutaneous Insulin Resistance

Many of the advantages of insulin-FDKP are related to its ultrarapidkinetics. However insulin-FDKP is typically administered by inhalationof a dry powder preparation. There is a class of patients who canreceive an additional benefit from this formulation due to its route ofadministration, namely patients with subcutaneous insulin resistance.This phenomenon is distinct from and unrelated to the insulin resistancetypically associated with type 2 diabetes, which is generally understoodto result from a reduced responsiveness of cells throughout the body toinsulin.

The phenomenon of subcutaneous insulin resistance is not universallyaccepted by experts in diabetes as a bona fide physiological state.Certainly its etiology is not well understood and indeed there may bemultiple factors that can lead to this condition. Nonetheless experiencewith inhalable insulin has demonstrated the clinical reality of thisphenomenon. There are patients who have required substantially greaterdoses of insulin than might otherwise be expected when treated withsubcutaneously administered insulin who upon switching to a pulmonaryinsulin require an amount of insulin more in line with what would beexpected based on their medical condition. Subcutaneous insulinresistance can also contribute to difficulty in establishing reasonablecontrol of hyperglycemia and in variability in the response to insulin.

To prospectively identify diabetes patients having subcutaneous insulinresistance several factors can be considered. First of all the patientwill be using high doses of insulin, especially compared to what wouldtypically be required based on their medical condition including bodyweight and state of progression of the disease. For example a high doseof insulin is one greater than 2 units/Kg/day. This criterion canfurther be paired with the patient having normal or near-normal basallevels of endogenous serum insulin, for example ≤50 pU/ml of insulin.Such patients typically will have type 2 diabetes in an early stage inthe progression of the disease. Alternatively high insulin usage can bepaired with lipoatrophy or lipodystrophy as diagnostic criteria.

In yet other alternative embodiments high insulin usage can be pairedwith very poorly controlled hyperglycemia as the selection criteria.Very poorly controlled hyperglycemia can be evidenced by three HbA1clevel determinations ≥9%, in a 12 month period despite treatment with anintensified insulin regimen, for example basal-bolus therapy, orcontinuous subcutaneous insulin infusion (CSII; that is, an insulinpump), etc., over a period ≥6 months. Commonly HbA1c levels aredetermined quarterly. It is preferred that the three HbA1c leveldeterminations ≥9%, be consecutive. In alternative embodiments verypoorly controlled hyperglycemia can be evidenced by two HbA1c leveldeterminations ≥9%, in a 6-9 month period.

In still further alternative embodiments high insulin usage can bepaired with life threatening glycemic instability as the criteria forselection. Life threatening glycemic instability can be characterized byperiods of hyperglycemia and/or hypoglycemia despite adherence to diet,exercise, and insulin regimens.

Accordingly embodiments herein provide methods of treating diabeticswith subcutaneous insulin resistance. These methods include a step forthe selection of patients with subcutaneous insulin resistance on thebasis of atypically high insulin dosage. In some embodiments the insulindosage is ≥2 units/Kg/day. In some embodiments the selection is furtherbased on the patient having normal or near-normal levels of endogenousinsulin. In some of these patients the basal level endogenous insulin is≤50 pU/ml. In other embodiments the selection is further based on thepatient being on an intensified insulin regimen and having three HbA1clevel determinations ≥9%, in a 12 month period. In still otherembodiments the selection is further based on the patient having lifethreatening glycemic instability characterized by periods ofhyperglycemia and/or hypoglycemia despite adherence to their insulinregimen and any diet or exercise regimen.

These methods also include a step of discontinuing treatment withsubcutaneously administered rapid-, short-, or intermediate-actinginsulin formulations. Note that patients who cannot produce sufficientinsulin to meet basal requirements need to continue taking basal insulineven if it is administered subcutaneously. Presently the only basal(long-acting) insulin formulations commercially available are forsubcutaneous administration. However other long acting insulins arebeing developed which could potentially be administered by other routesof administration and their use in the methods herein is contemplated.These methods also include the step of (initiating) treatment byadministration of prandial doses of insulin-FDKP by inhalation.

Further embodiments can include a step for confirming the diagnosis ofsubcutaneous insulin resistance by determining that a similar orimproved degree of glycemic control is achieved with a substantiallylower dosage of insulin. In some embodiments glycemic control isassessed as HbA1c level. In other embodiments it is assessed aspost-prandial and/or fasting blood glucose levels. In variousembodiments the insulin dosage (exclusive of any basal requirement) isreduced by ≥10, ≥20 or ≥50%, or more. In some embodiments the reduceddosage is assessed from measurements of serum insulin levels. In otherembodiments it is based on the dosage used and the relativebioavailability of the insulin formulations.

Combined Use of Ultrarapid Acting Insulin and Long Acting InsulinAnalogs

One mode of use of ultrarapid acting insulin is to use it in combinationwith a long acting insulin in a basal-bolus regimen. In basal-bolustherapy a long acting insulin is used to provide or supplement a basallevel of insulin and a bolus of short acting insulin is administered inconjunction with meals to handle the resultant increased glucose load.The various advantageous characteristics of ultrarapid acting insulinmake it an ideal choice for use as the short acting insulin in suchregimens.

Many long acting insulins are administered twice a day, but insulinglargine (sold as LANTUS® by Sanofi-Aventis) is approved and marketedfor once a day administration. According to the manufacturer'sprescribing information (March 2007 revision) insulin glargine providesrelatively constant glucose lowering activity over a 24-hour period andmay be administered any time during the day provided it is administeredat the same time every day. Additionally, insulin detemir (sold asLEVEMIR® by Novo Nordisk) is approved and marketed for administrationeither twice a day or once a day with the evening meal or at bedtime(manufacturer's prescribing information, Version 3 issued May 16, 2007).

In clinical trials it was found that an ultrarapid acting insulinformulation comprising insulin-FDKP used in combination with insulinglargine was effective in managing glucose excursions. In 7 pointglucose measurements insulin-FDKP was able to flatten the jagged patternresulting from post-prandial glucose excursions, but over the course ofthe day baseline blood glucose levels tended to rise. Similar behaviorwas observed in type 1 (See Example 2 and FIG. 12) and type 2 diabetics(see FIG. 13). There are several factors that may contribute to thisrise. Insulin resistance tends to rise over the course of the day.Additionally the insulin glargine used in the study was administered inthe evening before bedtime as contemplated in the manufacturer'sprescribing information. Thus the greatest demand for insulin activityis occurring late in the period of effectiveness of the insulin glarginedose when it is weakening.

In typical combinations insulin glargine is used in combination witheither a prandial short acting insulin or mixes of short andintermediate acting insulins administered before breakfast and dinner.Intermediate acting insulins are intended to provide glucose loweringactivity for both meal and between-meal periods. Even the marketed shortacting insulins exert the majority of their activity after most of ameal's nutrients have been absorbed. Thus in commonly used regimensinvolving combinations of insulin glargine and shorter acting insulins,the other insulins provide supplementary activity during waking hours.In contrast insulin-FDKP has a short duration of action, well matched tothe time period in which a meal produces an increased glucose load, butnot providing substantial insulin activity for baseline control. Thuswhen combined with an ultrarapid acting insulin such as insulin-FDKP anyinsufficiency of insulin glargine dose or duration will be exacerbatedas compared to established regimens. Insulin detemir has a shorterduration of action than insulin glargine so that when used once a daysuch deficiencies should be even more pronounced. To remediate sucheffects regimens combining the use of ultrarapid acting insulins and along acting insulin analog should specify that the long acting insulinanalog be administered early in waking hours, for example at breakfasttime or within 1, 2, 3 or 4 hours of waking. In some embodiments anearly dose of the long acting insulin analog is the only dose given inthe course of the day. In other embodiments the long acting insulinanalog is insulin glargine and it is administered twice a day, an earlydose and a late dose approximately 8 to 14, preferably 10-12, hourslater, for example around dinnertime. A typical cycle of sleeping andwaking, in which a person sleeps for an extended period, usually atnight, and then wakes and becomes active for the remainder of a day,naps notwithstanding, is assumed. Thus phrases such as within a certaintime after waking, early in waking hours, and similar terminology referto the point at which a subject wakes and initiates their dailyactivities.

Combined Use of Ultrarapid Acting Insulin and Basal Insulin Provided byInfusion

Insulin pumps are compact devices that deliver various forms of insulinat appropriate times to help control the blood glucose level. Usedcorrectly, these devices improve blood glucose control with fewerhypoglycemic episodes and better long-term control. The pumps areprogrammable and give patients a degree of freedom to vary what, when orhow much they eat by allowing insulin delivery rates to be adjusted fordifferent times of day. The latest models of insulin pumps arerelatively easy to use and convenient to carry. These newer pumps havebuilt-in dosage calculators that manage the complex insulin dosagecalculations previously performed by patients. Patients are able toprogram bolus doses to coincide with a meal as well as different basalinsulin delivery rates for different times of day, depending on changingneeds. These pumps also calculate how much insulin is still working fromthe previous bolus dose. Some pumps have additional smart features suchas programmable reminders and alerts, information and downloadcapabilities that allow the patient to save information to a computerfor accurate record-keeping, a carbohydrate database for calculating theamount of carbohydrate ingested in a meal, and certain safety features.

As an alternative to subcutaneous bolus injection of long acting insulinit is also possible to provide basal insulin by continuous infusion.This approach obviates the need for long acting insulin since insulin iscontinually provided. This approach can also avoid any drawbacksassociated with such preparations, for example increased immunogenicityor binding to receptors for insulin-like growth factors that can occurwith analogs. As the rate of infusion can be changed throughout the daywith this approach, the profile of basal insulin activity can be morereadily adjusted to variations in diet and individual physiology. (Thecapabilities of insulin pumps are more fully discussed in the sectiondealing with artificial pancreas systems, below). A common methodologywith insulin pumps is to aim to cover both prandial and basal needs byusing one of the rapid acting analogs. When the pump is only being usedto provide basal insulin—as with a prandial non-pumped ultrarapid actinginsulin—regular human insulin can be used. However for patients withless stable basal need the more rapid kinetics of the rapid actinganalogs can offer an advantage.

Accordingly embodiments provide a method of treating diabetes comprisinginfusing insulin with an insulin pump to meet basal insulin needs andadministering an ultrarapid acting insulin to meet prandial needs. Insome embodiments the pumped insulin is regular human insulin. In otherembodiments the pumped insulin is a rapid acting insulin analog. In oneembodiment the ultrarapid acting insulin formulation is insulin-FDKP. Inanother embodiment the administration of the ultrarapid acting insulinis by inhalation into the lungs.

Use of Ultrarapid Acting Insulin in Combination with or in Place of OralAntidiabetic Medications

Standard of care in the treatment of type 2 diabetes is defined andregularly updated in consensus statements published jointly by theAmerican Diabetes Association and the European Association for the Studyof Diabetes. The general course of treatment advocated, summarizedbelow, has remained fairly stable in recent years (compare for exampleNathan et al. Diabetes Care 29:1963-1972, 2006; Nathan et al. DiabetesCare 31:173-175, 2008; and Nathan et al. Diabetes Care 32:193-203, 2009)with the most significant change in the most recent update being theaddition of GLP-1 agonists to the treatment algorithm.

The course of treatment as advocated in these consensus statementsbegins with lifestyle changes plus the drug metformin at diagnosis (Step1). Lifestyle changes include improved diet and increased exercise.Metformin is a drug classified as a biguanide. Although historicallythese drugs have been described as insulin sensitizers, there primaryeffect is to reduce hepatic glucose output. This activity appears to bedependent on the presence of insulin and metformin treatment can beassociated with somewhat increased sensitivity to insulin. Howeveravoided herein is applying the term “insulin sensitizer” to thebiguanides as the mechanism of action is different from that of thethiazolidinediones which are now more commonly intended by the term andfor which the primary effect to increase insulin sensitivity. Asmetformin is present throughout the day its effect is observed as areduction in fasting blood glucose levels (FBG). Approximately 30% ofpatients cannot tolerate metformin, at least at dosages adequate foracceptable glycemic control, with gastrointestinal side-effects being aprimary issue. The prescribing information (January 2009 revision) formetformin (sold as GLUCOPHAGE® by Bristol-Myers Squibb) includescontraindications for use in patients with renal disease or dysfunction,hypersensitivity to the drug, or metabolic acidosis, as well as otherprecautions.

If adequate glycemic control is not attained (generally HbA1c remains≥7%) with Step 1 treatment Step 2 treatment calls for the addition of asecond agent. This can be basal insulin, a sulfonylurea, pioglitazone,or a GLP-1 agonist. If the two agents (the second agent not being basalinsulin) still do not establish adequate glycemic control the consensuscalls for either switching the second agent to basal insulin, our usinga combination of a sulfonylurea and pioglitazone as the second agent. Ifthe combination of a sulfonylurea and pioglitazone still does establishadequate glycemic control the consensus calls for switching the secondagent to basal insulin. By any of these paths the consensus advocatesthat the first insulin regimen used be basal insulin.

The sulfonylureas are insulin secretagogues, that is, they enhanceinsulin secretion. Included in this class are the drugs chlorpropamide,glyburide, gliclazide, glimepiride and glipizide. A major issue withthese agents is an increased risk of hypoglycemia, especially great withchlorpropamide and glyburide. Use of these agents has also beenimplicated in increased mortality from cardiovascular disease. Weightgain is common with these agents. Contraindications, precautions, anddrug interactions typical of the sulfonylureas can be found in theprescribing information for glipizide (sold as GLUCOTROL® by Pfizer;September 2006 revision). Concern has also been raised that insulinsecretagogues increase demand on an already overtaxed pancreascontributing to the progressive decrease in β-cell function and limitingtheir long term usefulness. Other insulin secretagogues are known suchas the glinides, for example repaglinide and nateglinide. The risk ofweight gain with these agents is similar to the sulfonylureas, but therisk of hypoglycemia may not be as elevated. GLP-1 agonists and DPP-4(dipeptidyl peptidase-4) inhibitors can also be considered insulinsecretagogues. As used, insulin secretagogues provide their activitythroughout the day so that their effect is readily seen as a reductionin FBG.

Pioglitazone (sold as ACTOS® by Takeda Pharmaceuticals) is athiazolidinedione (glitazone, TZD) which increase the sensitivity ofmuscle, fat, and liver to insulin thereby counteracting the insulinresistance aspect of type 2 diabetes, and are therefore commonlyreferred to as insulin sensitizers. TZDs have been associated with fluidretention and congestive heart failure and also with increased rates ofbone fracture, especially in women with osteoporosis. The TZDs alsoinclude the drug rosiglitazone (sold as AVANDIA® by GlaxoSmithKline)which has been further associated with myocardial ischemia. These andother side-effects, precautions, etc., such as weight gain are reportingin the manufacturer's prescribing information for ACTOS® (August 2008version) and AVANDIA® (October 2008 version).

The third (and last) step in the consensus algorithm is reached if—orwhen as type 2 diabetes is a progressive disease—adequate glycemiccontrol is not attained by treatment including basal insulin under thesecond step. The third step advocates that the lifestyle changes andmetformin treatment of the previous stages be continued along withintensified insulin treatment. As described intensified treatment caninclude prandial use of rapid acting insulin analogs, but definitelyinvolves the continued use of basal insulin.

Patient populations treated according to the embodiments hereindisclosed are distinct from those most commonly receiving insulintherapies. Indeed the factors that might impel a clinician to prescribeinsulin to individuals according to current paradigms do not shed anylight on the relative effectiveness of an ultrarapid acting insulin ascompared to oral antidiabetic agents especially given the distinctpharmacokinetic profiles of the insulin preparations available.Moreover, as seen above use of insulin typically begins with basalinsulin, with prandial insulins being added only after the failure ofbasal insulin alone. In contrast the methods disclosed herein involveuse of prandial ultrarapid acting insulin early in the progression oftreatment.

Patients with early stage insulin disorders can be divided into varioussubpopulations and treated according to various embodiments of thepresent invention. Some persons make sufficient insulin to maintain anon-hyperglycemic fasting blood glucose level but cannot avoid acutefluctuations in blood glucose after eating. Early type 2 diabetics canoften use diet and exercise to control even substantial hyperglycemia,but will have already lost their early phase insulin release. In currentpractice patients failing diet and exercise are most often next treatedwith a suppressor of hepatic glucose output, such as metformin, with thegoal of overcoming insulin resistance and improving the effectiveness ofthe insulin that is produced. In embodiments disclosed herein, thesepatients are administered a prandial, early phase-mimicking insulinpreparation instead of, or in addition to, the insulin sensitizer. Lessoften (and previously) the first oral medication offered diabetics wasan insulin secretagogue, such as a sulfonylurea, to increase insulinsecretion. More commonly (and currently) such agents are used incombination with a suppressor of hepatic glucose output as a subsequentstep in treatment if use of the sensitizer alone does not provide thedesired level of glycemic control. However, use of secretagogues canalso lead to weight gain and hypoglycemic events so, in a oneembodiment, a prandial, early phase-mimicking insulin preparation isused instead of a secretagogue in such combination treatments.

Both fasting and postprandial blood glucose levels contribute toelevation of HbA1c levels. Ultrarapid acting insulin preparations canadvantageously impact both fasting and postprandial blood glucoselevels. It was initially appreciated that they are particularly wellsuited to addressing control of postprandial blood glucose in contrastwith basal insulins or insulin secretagogues, or even short actinginsulins. This is understood to be due in part to their more rapidsuppression of endogenous glucose production (see Example 1). Thusembodiments disclosed herein are directed to patients with poorlycontrolled postprandial blood glucose or in whom the lack of glycemiccontrol is more strongly associated with elevated postprandial bloodglucose. For example patients with a lesser degree of insulin resistancemay be able to produce sufficient insulin to provide substantial controlof fasting blood glucose and in some embodiments can be selected fortreatment with ultrarapid insulin alone. In comparison patients with ahigher degree of insulin resistance may have poor control of bothfasting and postprandial blood glucose and in embodiments would beselected for treatment with ultrarapid insulin and an oral antidiabeticagent in combination.

Ultrarapid Acting Insulin and Suppressors of Hepatic Glucose Output

Both ultrarapid acting insulin and biguanide drugs such as metformin actas suppressors of hepatic glucose release. However as used the drugsexert their effect around the clock whereas prandial ultrarapid actinginsulin exerts this effect more particularly following meals. Thusultrarapid acting insulin can substitute for or augment the activity ofthe oral suppressors of hepatic glucose output.

Accordingly in one embodiment ultrarapid acting insulin is used intreating a subject with type 2 diabetes in need of improved glycemiccontrol with well or moderately controlled FBG but poorly controlledPPG. In various aspects of the embodiment need for improved glycemiccontrol is determined as HbA1c level, 1- or 2-hour PPG, or oxidativestress. In some embodiments well controlled FBG is FBG ≤110 or ≤130mg/dL. In some embodiment moderately controlled FBG is FBG ≤154 mg/dL,≤180, or ≤192 mg/dL. Studies have determined that at HbA1c levels 8.4%at least half of overall hyperglycemia is due to PPG (Monnier, L. et al.Diabetes Care 26:881-885, 2003). Thus in some embodiments a subject withwell or moderately controlled FBG but poorly controlled PPG is a subjectwith HbA1c ≤8.4%. (An HbA1c of 8.4% corresponds to a mean plasma glucoselevel of approximately 192-198 mg/dL; see Diabetes Care 32,suppl.1:S13-561, 2009, especially tables 8 and 9). In variousembodiments a subject with poorly controlled PPG in one with 1- or2-hour PPG ≥140, or ≥180, or ≥200 mg/dL. It should be noted thatsubjects whose 2-hour PPG following a 75 g glucose challenge was ≥200mg/dL had an almost doubled risk of mortality than those whose 2-hourPPG was <200 mg/dL regardless of their FPG (Lancet 354:617-621, 1999).In one embodiment the subject is not currently receiving any drugtreatment and ultrarapid insulin is used as the sole pharmacologicagent. In another embodiment the subject is undergoing treatment with anoral suppressors of hepatic glucose output and prandial ultrarapidinsulin is added to their treatment regimen. In one embodiment the oralsuppressors of hepatic glucose output is metformin. In one embodimentthe ultrarapid acting insulin formulation is insulin-FDKP. In anotherembodiment the administration of the ultrarapid acting insulin is byinhalation into the lungs.

In other embodiments, a subject with type 2 diabetes in need of improvedglycemic control could benefit from treatment with a suppressor ofhepatic glucose output, but such oral agents are contraindicated or nottolerated, and ultrarapid acting insulin is used instead. In a variationthe oral agent is not tolerated in sufficient dosage and ultrarapidacting insulin is used to supplement its activity.

Ultrarapid Acting Insulin and Insulin Secretagogues

Insulin secretagogues such as the sulfonylureas and the glinidesincrease insulin secretion and thereby insulin concentrations incirculation. Ultrarapid acting insulin preparations also increaseinsulin concentrations in circulation. However as used the drugs exerttheir effect around the clock whereas prandial ultrarapid acting insulinexerts this effect more particularly following meals. Thus ultrarapidacting insulin can substitute for the activity of the insulinsecretagogue. In one embodiment the ultrarapid acting insulinformulation is insulin-FDKP. In another embodiment the administration ofthe ultrarapid acting insulin is by inhalation into the lungs.

Accordingly in one embodiment, a patient under treatment with asuppressor of hepatic glucose output and an insulin secretagoguediscontinues treatment with the secretagogue and institutes treatmentwith an ultrarapid acting insulin. In a related embodiment a patientunder treatment with a suppressor of hepatic glucose output who is acandidate for treatment with an insulin secretagogue and insteadinstitutes treatment with an ultrarapid acting insulin rather than witha secretagogue. In one embodiment the patient is in need of improvedglycemic control. In various aspects of the embodiment need for improvedglycemic control is determined as HbA1c level, 1- or 2-hour PPG, oroxidative stress.

In other embodiments a subject with type 2 diabetes could benefit fromtreatment with an insulin secretogogue, but such oral agents arecontraindicated or not tolerated, and ultrarapid acting insulin is usedinstead. In other embodiments the patient is in need of reducing therisk of hypoglycemia or weight gain.

Ultrarapid Acting Insulin and Insulin Sensitizers

Insulin sensitizers, such as pioglitazone and the other TZDs improveinsulin utilization in various tissues thereby reducing insulinresistance and leading to a reduction in circulating insulin levels.Treatment with TZDs results in notable decreases in FBG. Treatment withprandial ultrarapid acting insulin leads to a reduction in FBG. This isdespite the fact that there is no direct glucose eliminating activitydue to prandial ultrarapid acting insulin during fasting periods. Theimpact of ultrarapid acting insulin preparations on fasting bloodglucose levels was unexpected and suggests that they can reduce insulinresistance or act as an insulin sensitizer. Interestingly the rapidinsulin concentration peak obtained with ultrarapid acting potentiatessubsequent insulin activity. This is particularly noticeable in type 2diabetics in the time frame immediately following administration howeverthe effect may be longer lived. Thus treatment with prandial ultrarapidacting insulin has effects similar to insulin sensitizers.

Accordingly, in some embodiments, patients are selected for treatmentcomprising an ultrarapid acting insulin on the basis of having a highdegree of insulin resistance. In other embodiments patients who wouldbenefit from treatment with an insulin sensitizer, such as a TZD, buthave a sensitivity to the drug or are otherwise contra-indicated, aretreated with an ultrarapid acting insulin in place of the drug. Forexample TZDs can be contraindicated in women with osteoporesis.

Patients who can benefit from treatment with prandial ultrarapid actinginsulin according to various embodiments include those who obtaininadequate glycemic control with an insulin sensitizer and wouldotherwise have an insulin secretagogue added to their treatment regimen,or those who obtain inadequate glycemic control with a combination of aninsulin sensitizer and an insulin secretagogue. Subsets of these groupsinclude those who further are needle-phobic or would otherwise want toavoid injections, and those who further are obese, overweight, orotherwise desire to avoid or minimize weight gain or need to loseweight. Additionally elevated insulin levels are associated with agreater occurrence of breast cancer. Thus persons with an elevated riskof breast cancer can particularly benefit from a lowering of insulinresistance. In one embodiment the ultrarapid-acting insulin formulationis insulin-FDKP. In another embodiment the administration of theultrarapid acting insulin is by inhalation into the lungs.

Prandial Ultrarapid Insulin Versus Basal Insulin

When treatment with two oral medications does not provide adequateglycemic control standard of care offers paths to the use of basalinsulin or use of a third oral medication. The choice to add a thirdoral medication instead of adding insulin is often influenced byreticence to accept daily injections even in the absence of an outrightneedle phobia, the risk of hypoglycemia, and the likelihood of weightgain. Thus embodiments of the invention provide a successor treatment tocombination oral therapy that includes insulin, but is needle-free andminimizes or eliminates weight gain. The inhalable insulin EXUBERA®,because of its subcutaneously delivered insulin-like kinetics, would notbe expected to confer the same benefits as an ultrarapid acting insulinpreparation. This use shows that prandial ultrarapid insulin offers aunique alternative to the early use of basal insulin generally, and thatoffers particular advantage to patient populations in which needle use,the risk of hypoglycemia, or the prospect of weight gain areparticularly problematic.

Patients who can benefit from treatment according to various embodimentsdisclosed herein include those who obtain inadequate glycemic controlwith an oral suppressors of hepatic glucose output and would otherwisehave an insulin secretagogue added to their treatment regimen, or thosewho obtain inadequate glycemic control with a combination of an oralsuppressor of hepatic glucose output and an insulin secretagogue.Subsets of these groups include those who further are needle-phobic orwould otherwise want to avoid injections, and those who further areobese, overweight, or otherwise desire to avoid weight gain or need tolose weight.

EXAMPLES Example 1

The experiments were conducted to identify the effect of an ultrarapidacting insulin, specifically a formulation for inhalation comprisinginsulin-FDKP, when compared to subcutaneously administered insulinlispro (lispro, HUMALOG®, Eli Lilly & Co.) and an inhaled recombinanthuman insulin (EXUBERA®, Pfizer Inc.) on endogenous glucose productionafter a meal challenge and during a euglycemic glucose clamp procedurein subjects with type 2 diabetes. The insulin-FDKP formulation isadministered to the subjects by oral inhalation using a MEDTONE® drypowder inhaler (MannKind Corp.).

Following the completion of the meal challenge, the data was analyzed asper the statistical analysis plan. Total insulin exposure was found tobe approximately 40% greater following the administration of 12 U lisprothan following either 45 U insulin-FDKP (TI) or 4 mg EXUBERA®. Hence,the study was redesigned, and subjects did not proceed to the euglycemicglucose clamp portion of the study under the original protocol andtreatments (4 mg EXUBERA®, 45 U TI and 12 U lispro). The study wasamended (A1) and included 12 subjects (10 were reenrolled from the firstmeal challenge), and only two treatments, which were 10 U lispro and 60and 90 U TI. The doses were selected based on the relativebioavailability observed following the first meal challenge (OP), whereunder an assumption of linear kinetics, 10 U lispro and 60 U TI wouldresult in similar exposure. The 90 U dose group was included to assessthe effect of the highest dose group of TI studied in Phase 3 trials.Six of the 12 subjects received 60 U TI and the other 6 subjectsreceived 90 U TI. All 12 subjects received 10 U lispro in a crossoverfashion.

Methods and results below are described in terms of the OriginalProtocol (OP), which includes the meal challenge in 18 subjects withthree treatments (EXUBERA®, lispro and TI) and Amendment 1 (A1), whichincludes 12 subjects treated with only TI and lispro.

Subjects with insulin-treated type 2 diabetes participated in the study.The subjects were screened and evaluated before, during and after theexperiments and their data analyzed as described below. Subjects wereselected based on several key inclusion criteria, including, male andfemale, having ≥18 and ≤70 years of age with clinical diagnosis of type2 diabetes mellitus for ≥12 months. The subjects selected for the studyalso had stable anti-diabetic regimen with insulin for the previous 3months; HbA1c ≤8.5%; Body Mass Index (BMI) between ≤34 kg/m² and ≥25kg/m²; urine cotinine ≤100 ng/mL; PFTs of FEV1 ≥70% of predicted value,single breath CO diffusing capacity (DLco uncorrected) ≥70% ofpredicted. Subjects had also been treated with oral antidiabeticmedication within the previous 3 months; total daily insulin requirementof ≥1.2 IU/kg body weight. Criteria for exclusion from the study alsoincluded unstable diabetes control and/or evidence of seriouscomplications of diabetes (e.g., autonomic neuropathy); serumcreatinine >1.8 mg/dL in female subjects and >2.0 mg/dL in malesubjects. Other clinically important pulmonary disease was confirmed bydocumented history or pulmonary function testing.

Under OP, the study was planned to be a randomized, open label, 3-waycross-over study. The visits comprised an initial screening visit, 3sequential treatment visits for the meal challenge test followed by aminimum 8-week (up to a maximum of 12 weeks) blood-loss recovery period,an interim safety visit, 3 sequential visits for the glucose clampprocedure, and a final close-out visit. At this analysis all patients atleast had completed the meal challenge visits and only those data havebeen used. The screening visit(s) (V1) occurred 1 to 21 days before thefirst treatment visit (V2) with 7 to 21 days elapsing betweentreatment-visits (V2, V3, and V4) for the meal challenge test. A minimumof 8 weeks elapsed between V4 and the next treatment visit, (V6). Anadditional safety visit (V5) was scheduled 1-3 days prior to the firstof 3 glucose clamp procedures (V6). The glucose clamp procedure occurredat 3 visits, Visits V6, V7, and V8, with 7 to 21 days elapsing betweenthe visits. A final visit (V9) occurred 2 to 10 days after V8, to assessphysical examination such as body weight and height.

Under A1, the study was planned to be a randomized, open label, 2-waycross-over study. The visits comprised an initial screening visit, 2sequential treatment visits for the meal challenge test followed by aminimum 4-week (up to a maximum of 12 weeks) blood-loss recovery period,an interim safety visit, 2 sequential visits for the glucose clampprocedure, and a final close-out visit. The screening visit(s) (V1)occurred 1 to 21 days before the first treatment visit (V2) with 7 to 21days elapsing between treatment-visits (V2 and V3) for the mealchallenge test. A minimum of 4 weeks elapsed between V3 and the nexttreatment visit, (V5). An additional safety visit (V4) was scheduled 1-3days prior to the first of 3 glucose clamp procedures (V5). The glucoseclamp procedure occurred at 2 visits, Visits V5 and V7, with 7 to 21days elapsing between the visits. A final visit (V8) occurred 2 to 10days after V7, to assess physical examination such as body weight andheight.

Each treatment visit during the meal challenge had the subjectshospitalized in the clinical unit the night before initiation oftreatment. At the first treatment visit (V2) for the meal challengetest, subjects were randomly allocated to a treatment order forinsulin-FDKP, insulin Lispro or EXUBERA® (OP) and insulin-FDKP andlispro (A1) based on a cross-over design. Each subject followed the samerandomization order for the glucose-clamp procedures as for the mealchallenge tests.

During the study, periodic blood draws for determination ofpharmacokinetic and/or pharmacodynamic parameters, and safety were takenbeginning at 12 hours prior to onset of the treatment regimens and mealchallenge, and thereafter for a period of 8 hours. Screening testing andall 3 meal challenge tests required in combination a total of 409.5 mLof blood for analysis and evaluation of the treatments (OP) and 279 mLblood for A1. The glucose clamp procedure visits, final visit, and theinterim safety visit required a total of 514.2 mL of blood (OP) and 365mL blood for A1 for the analysis and evaluation of the treatments. Thetotal blood volume needed for A1 studies was 644 mL per subject.Radiolabeled D₂-glucose infusion was administered to subjects 12 hoursprior to onset of the meal challenge and insulin treatment.

Meal Challenge Test:

BOOST PLUS® (12 fl. oz.) consisting of 67.5 g carbohydrate, 21 gprotein, 21 g fat, energy content 540 kcal was used for the mealchallenge test. The BOOST PLUS® was enriched with U-¹³C-glucose todetermine the amount of absorbed glucose. Concurrent enriched continuousinfusion of 6,6-²H₂ glucose was used to assess endogenous glucoseproduction EGP. Sampling for fasting EGP (f-EGP) occurred before thestart of an intravenous insulin lispro infusion, i.e., at the end of a7-hour period of enriched infusion of 6,6-²H₂ glucose under OP. In A1,the continuous insulin infusion was conducted using either insulinlispro (for subjects treated with TI) or regular human insulin (forsubjects treated with lispro). Baseline blood glucose concentrations of90 mg/dL (OP) and 110 mg/dL (A1) were established and maintained byvariable infusion of insulin and 20% glucose enriched with 6,6-²H₂glucose over a period of at least 5 hours prior to dosing withinsulin-FDKP, insulin lispro, or EXUBERA® (OP) or insulin-FDKP andlispro under A1. Insulin Lispro infusion rate (OP) and lispro or RHIinfusion rate (A1) was fixed at the lowest possible level 90 minutesprior to treatment dose. Following dosing, blood glucose concentrationswere kept from falling below 90 mg/dL (OP) and 75 mg/dL (A1) by aglucose infusion.

Dosing with the test treatments was performed with administration of adose of 45 U of Insulin-FDKP, 12 U of subcutaneous insulin lispro, or 4mg of recombinant human insulin (EXUBERA®) administered by oralinhalation at time point 0 (OP), or 10 U subcutaneous lispro and 60 or90 U TI (A1) immediately prior to BOOST PLUS® ingestion. Under OP, thedose for insulin lispro was selected based on information obtained fromthe regulatory label. The dose selected for EXUBERA® was obtained bymeans of back calculation of the most commonly used dose informationpresented to the FDA Advisory Committee in the EXUBERA® BriefingDocument. The insulin-FDKP dose was derived from results in completedphase 2 and 3 clinical studies carried out by MannKind Corporation, theassignee of the application. Under A1, the doses were calculated basedon insulin exposure observed under OP. Blood glucose concentrations weremeasured at regular intervals from arterialized venous blood samples.The amount of orally absorbed glucose was estimated by determination ofU-¹³C-glucose. EGP was determined by measurement of 6,6-²H₂ glucoseapplying the modified calculations for the non-steady state (R. Hovorka,H. Jayatillake, E. Rogatsky, V. Tomuta, T. Hovorka, and D. T. Stein.Calculating glucose fluxes during meal tolerance test: a newcomputational approach. Am. J. Physiol Endocrinol. Metab 293(2):E610-E619, 2007). C-peptide concentrations were measured pre- andpost-dose to assess endogenous insulin secretion. In addition, glucagonand free fatty acid concentrations were also determined.

Glucose-Clamp Procedure:

An enriched continuous infusion of 6,6-²H₂ glucose was used to assessEGP. Blood samples to determine fasting EGP (f-EGP) were taken beforethe start of an intravenous insulin infusion, i.e., at the end of a7-hour period of enriched infusion of 6,6-²H₂ glucose into the subjects.Baseline blood glucose concentrations of 90 mg/dL (OP) and 110 mg/dL(A1) were established and maintained by variable infusion of insulin and20% glucose enriched with 6,6-²H₂ glucose by means of a Biostator deviceover a period of at least 4 hours prior to dosing with insulin-FDKP,insulin lispro, or EXUBERA® (OP) and either lispro or TI under A1.

Dosing with the test treatments was performed by administering a dose of45 U of Insulin-FDKP, 12 U of sc Insulin Lispro, or 4 mg of recombinanthuman insulin (EXUBERA®) under OP, and lispro or 60 or 90 U of TI (A1)in the same order as for the meal challenge test for each individualsubject. EGP was determined for each subject by measuring 6,6-²H₂glucose in the blood samples and applying the modified calculations byHovorka et al. (ibid) for the non steady-state. Serum C-peptideconcentrations were measured pre- and post-dose to assess endogenousinsulin secretion. In addition, glucagon and free fatty acidconcentrations were determined at regular intervals. All subjects werereturned to their prior anti-diabetic treatment regimens at the end ofeach treatment visit.

The results of the OP portion of the study are presented in FIGS. 3-6.FIG. 3 is a graphical representation of data plotted from blood samplevalues obtained from patients in this study. In particular, FIG. 3 showsmeasured blood glucose concentrations at various times after the mealchallenge in patients with type 2 diabetes who were treated with insulinlispro (1), EXUBERA® (2) and an insulin formulation comprising fumaryldiketopiperazine (insulin-FDKP, TI, 3) at the onset of the meal. Thetime points in the data plots of each treatment curve represent the meanvalue for all samples analyzed in the study. The graph also shows theexogenous glucose infusions administered to the patients as neededduring the experiments to maintain euglycemic (remain above 90 mg/dl ofblood glucose) levels following administration of each of the treatmentsand represented in the graph as 1a, 2a, and 3a, respectively for insulinlispro, EXUBERA® and insulin-FDKP. As seen in FIG. 3, the glucose levelsdiffer for all three treatments. It is evident from the data that theinsulin lispro-treated subjects were overdosed due to the need to givethe patients repeated glucose infusions to remain above 90 mg/dL. Thegraph also shows that subjects treated with insulin-FDKP had reducedglucose levels much earlier than the other treatments, with somesubjects under this treatment requiring glucose infusions to remainabove 90 mg/dL at early stages of the study. However, the insulin-FDKPtreated subjects did not require further glucose infusion until aboutsix hours after onset of treatment, which indicate that this treatmentwas effective at maintaining glycemic control for an extended period oftime. The data also show that the glucose concentration was controlledin all subjects by all treatments, however, in subjects treated withinsulin-FDKP, glucose control occurred more effectively from onset toabout 120 minutes after treatment. Minimal glucose infusions were needed(following the initial phase) until after six hours followinginsulin-FDKP administration (when glucose demand is likely driven by thebaseline insulin infusion) as compared to EXUBERA® and lispro treatedsubjects who were infused with glucose at about 4 and 3 hoursrespectively, post-treatment. The data indicate that patients treatedwith lispro and EXUBERA® may have reached hypoglycemic levelspost-dosing if glucose were not infused. Hence, insulin-FDKP may be ableto maintain the blood glucose above hypoglycemic levels moreefficaciously than the other treatments for a longer period of time.

FIG. 4 is a graph of data obtained from the patients in the studydescribed above showing the rate of absorption of glucose for a periodof time after a meal in patients with type 2 diabetes who were treatedwith insulin lispro, EXUBERA® and an insulin-FDKP formulationimmediately prior to of the meal. The time points in the data plots ofeach treatment curve represent the mean value for all samples analyzedin the experiments. The data in FIG. 4 show that the subjects treatedwith the three treatments all exhibited similar patterns for the rate ofglucose absorption from the meal taken. Therefore, the data indicatethat the treatment did not alter the rate of glucose absorption in thesubjects treated from a meal.

FIG. 5 is a graph of data obtained from experiments in which endogenousglucose production after a meal was determined in patients with type 2diabetes who were treated with insulin lispro, EXUBERA® and aninsulin-FDKP formulation at the onset of the meal. The time points inthe data plots in each treatment curve represent the mean value for allsamples analyzed in the experiments. The data curves for the threetreatments show that all three treatments were effective in inhibitingendogenous glucose production in the treated subjects to a similardegree, suggesting a physiologic maximum for this effect. Notablysubjects treated with insulin-FDKP exhibited peak inhibition ofendogenous glucose production at a much faster or earlier time (at about40 minutes) after treatment as compared to insulin lispro (at about 80minutes) and EXUBERA® (at about 125 minutes).

FIG. 6 is a graph of data obtained from experiments that monitored therate of glucose disappearance for a period of time in subjects with type2 diabetes, who were treated with insulin lispro, EXUBERA® and aninsulin-FDKP formulation at the onset of the meal as described above.The time points in the data plots for each treatment curve represent themean value for all samples analyzed in the experiments. In addition, theglucose disappearance rate was standardized to account for eachsubject's body weight by dividing the rate of glucose disappearance bythe body weight of the subject. The data show that the rate of glucosedisappearance or utilization for the subjects was different for alltreatments. Notably, the glucose disappearance rate for insulin-FDKP wasevidently much sooner than for insulin lispro or EXUBERA®. It wassubstantial at the first measurement after dosing, about 10 minutes postdosing, whereas the glucose disappearance rate for the others did notsignificantly depart from baseline until about 30 minutes. The glucosedisappearance rate for insulin-FDKP peaked at about 40 minutes afterdosing, much earlier as compared to insulin lispro (at about 120minutes) and EXUBERA® (at about 150 minutes).

The study also indicated that measurements of C-peptide (data not shown)clearly show that an increase in C-peptide concentrations was delayed inthe TI group when compared to lispro and EXUBERA®. This later increasein C-peptide (and endogenous insulin production), is related to theability of each of the exogenous insulins to control the glucoseabsorbed from the meal, and appears to be related to the shape of theinsulin profiles for each treatment group. The slow rise in insulinconcentrations following EXUBERA® and lispro (median t_(max) of 113 and75 minutes, respectively, versus a t_(max) of 20 minutes in the TIgroup, results in a decreased ability to control glucose early followingthe meal, and therefore, in an earlier increase in the patients'endogenous insulin response. The delay of endogenous insulin productionin the TI group, however, indicates better control of blood glucoseearly in the study, when TI concentrations are high.

In summary, the data from the study indicate that insulin-FDKP was amarkedly and surprisingly more efficacious treatment in patient withtype 2 diabetes than existing treatments, i.e., insulin lispro andEXUBERA®, in that the insulin-FDKP treatment was faster at inhibitingendogenous glucose production and faster at inducing the glucosedisappearance or utilization rate. It is surprising that EXUBERA® is somuch slower in these parameters than even insulin lispro, to which it isotherwise kinetically similar. This further emphasizes thenon-equivalence of these two inhalable insulin preparations (i.e.insulin-FDKP and EXUBERA®) already evident from their differentkinetics.

The results of the A1 portion of the study are presented in FIGS. 7-11.FIG. 7 is a graphical representation of data plotted from blood samplesvalues obtained from subjects in this study. In particular, FIG. 7 showsthe mean insulin concentration-time profiles for the three treatments.Total insulin concentrations (the sum of regular human insulin andlispro concentrations at each time point) are shown, as all of theinsulin in the system is associated with the elicited response.Following both 60 and 90 U of insulin-FDKP administration, observed peakinsulin concentrations are much higher (196 and 216 μU/mL following TIversus 83 μU/mL following lispro) and occur much earlier (median t_(max)of 15 and 17.5 minutes following TI versus 60 minutes following lispro)when compared to peak insulin concentrations following lispro treatment.However, average exposure was very similar between the three groups,with total insulin AUC of 24,384, 18,616 and 19,575 μU/mL*min for thetwo TI dose groups and lispro, respectively.

FIG. 8 shows measured blood glucose concentrations at various timesafter the meal challenge in patients with type 2 diabetes who weretreated with either 60 or 90 U of insulin formulation comprising fumaryldiketopiperazine (insulin-FDKP, 2, 3), and insulin lispro (1) at theonset of the meal. The time points in the data plots of each treatmentcurve represent the mean value for all samples analyzed in the study.The graph also shows the exogenous glucose infusions administered to thepatients as needed during the experiments to maintain euglycemic (toremain above 75 mg/dL of blood glucose) levels following administrationof each of the treatments and represented in the graph as 1a, 2a, and3a, respectively for 60 and 90 U of insulin-FDKP, and insulin lispro,respectively. As seen in FIG. 7, the glucose profile shapes differ forall three treatments, however, maximal glucose levels are very similar,and glucose was controlled by all three treatments. The graph also showsthat subjects treated with either dose of insulin-FDKP had reducedglucose levels much earlier than following lispro administration, withmore efficacious glucose control occurring within the first 120-180minutes post-dose. Subjects treated with both 90 U insulin-FDKP andlispro required some additional glucose infusions to maintain bloodglucose at or above 75 mg/dL. Following 90 U TI, some subjects requiredadditional glucose infusions in the earlier post-dose period, andfollowing lispro, these infusions were needed in the latter period. Thisphenomenon can be due to the rapid glucose clearance rate observed inthe patients treated with 90 U of insulin FDKP. Minimal glucoseinfusions were needed (following the initial phase) until the end of thestudy following insulin-FDKP administration (when glucose demand islikely due to the baseline insulin infusion) as compared to lisprotreated subjects, who were infused with glucose between 5 and 8 hourspost-treatment. This result is indicative of an elevated insulinpresence and activity following lispro treatment in a timeframe wellbeyond expected glucose absorption following a meal. Additionally, it isevident that the 90 U insulin-FDKP group controlled blood glucose levelsmore efficiently than the group treated with the 60 U dose ofinsulin-FDKP, resulting in lower blood glucose levels in the 0-180minute time period. Due to the better control, less endogenous insulinwas secreted by the patients receiving the 90 U insulin-FDKP dose, andthus endogenous insulin contributed a small portion of the total insulinprofile of the individuals in this group. Moreover, the data indicatethat more endogenous insulin contributed to the total insulin profile ofthe group treated with 60 U dose of insulin-FDKP, making the averageinsulin profiles similar for the two groups tested.

FIG. 9 is a graph of data obtained from the patients in the studydescribed above showing the rate of absorption of glucose for a periodof time after a meal in patients with type 2 diabetes who were treatedwith 10 U insulin lispro, and 60 and 90 U of an insulin-FDKP formulationimmediately prior to the meal. The time points in the data plots of eachtreatment curve represent the mean value for all samples analyzed in theexperiments. The data in FIG. 9 show that the subjects treated with thethree treatments all exhibited similar pattern of the rate of glucoseabsorption from the meal taken. Therefore, the data indicate that thetreatment did not alter the rate of glucose absorption in the subjectstreated from a meal.

FIG. 10 is a graph of data obtained from experiments in which endogenousglucose production after a meal was determined in patients with type 2diabetes who were treated with 10 U of insulin lispro and either 60 or90 U of an insulin-FDKP formulation at the onset of the meal. The timepoints in the data plots in each treatment curve represent the meanvalue for all samples analyzed in the experiments. Two subjects treatedwith 90 U insulin-FDKP were excluded from the analysis due to difficultyin interpreting the modeled results. The data curves for the threetreatments show that all three treatments were effective in inhibitingendogenous glucose production in the treated subjects, to a similardegree between the 60 U insulin-FDKP and 10 U lispro treatments. Thedata also indicate that the 90 U insulin-FDKP treatment has a greaterand faster effect on inhibiting endogenous glucose production. Notablysubjects treated with insulin-FDKP exhibited peak inhibition ofendogenous glucose production at a much faster or earlier time (at about40 and 60 minutes for the two treatments) following dosing, than insulinlispro (at about 100 minutes).

FIG. 11 is a graph of data obtained from experiments that monitored therate of glucose disappearance for a period of time in subjects with type2 diabetes, who were treated with 10 U of insulin lispro and either 60or 90 U of an insulin-FDKP formulation at the onset of the meal asdescribed above. The time points in the data plots for each treatmentcurve represent the mean value for all samples analyzed in theexperiments. In addition, the glucose disappearance rate wasstandardized to account for each subject's body weight by dividing therate of glucose disappearance by the body weight of the subject. Thedata show that the rate of glucose disappearance or utilization for thesubjects was different for all treatments. Notably, the glucosedisappearance rate for both the 60 U and 90 U insulin-FDKP dose groupswas evident much earlier than for insulin lispro. The glucosedisappearance rate of the insulin-FDKP treated groups was substantial atthe first measurement after dosing, about 5 minutes post dosing, andpeaked at about 30-50 minutes after dosing, much earlier as compared toinsulin lispro (at about 100 minutes).

In summary, the data from the study indicate that insulin-FDKP wasmarkedly a more efficacious treatment in patient with type 2 diabetesthan existing treatments, i.e., insulin lispro, in that the insulin-FDKPtreatment was faster at inhibiting endogenous glucose production andfaster at inducing the glucose disappearance or utilization rate inpatients with type 2 diabetes. Insulin-FDKP effect on EGP and glucoseutilization appeared to increase with increasing dose.

Example 2 A Prospective, Multi-Center, Open-Label, Randomized,Controlled Clinical Trial Comparing the Efficacy and Safety in Subjectswith Type 1 Diabetes Receiving SC Basal Insulin and Prandial Inhalationof Insulin-FDKP Versus SC Basal and Prandial Insulin Over a 52-WeekTreatment Period and a 4-Week Follow-Up

This was a prospective, multi-country, multicenter, open label,randomized, controlled clinical trial comparing glycemic control insubjects with type 1 diabetes receiving basal insulin and prandialinsulin-FDKP (TI) Inhalation Powder (TI Inhalation Powder group) withsubjects receiving basal insulin and SC rapid-acting insulin aspart(comparator group). This study included a 52-week treatment phase and a4-week follow-up phase. During the 4-week follow-up phase, pulmonaryfunction and select clinical laboratory assessments were scheduled.

The study began with enrollment at Week −3. Subjects received a completebattery of safety and eligibility assessments, including HbA1c andfasting plasma glucose (FPG).

At Week −1, subjects were randomized to one of the following 2treatments:

Basal insulin+prandial TI Inhalation Powder

Basal insulin+prandial SC rapid-acting insulin

At Week −1, subjects again completed the first three components of theInsulin Treatment Questionnaire (ITQ) for the purpose of assessingtest-retest reliability only). After completing the questionnaire,subjects randomized to the TI Inhalation Powder group were trained onthe MEDTONE® Inhaler using TECHNOSPHERE®/insulin (insulin-FDKP)inhalation powder; subjects in the comparator group were trained in theuse of the NOVOLOG® pens; all subjects were trained in administration ofLANTUS®. Additionally, all subjects were trained on a blood glucosemonitoring (HBGM) meter provided at the beginning of the trial and diaryand received diabetes education. Any training was repeated at Week 0, ifneeded.

At the beginning of the treatment phase, subjects had severaltitration/dose evaluation visits to adjust insulin therapy. Titrationvisits occurred once a week for the first 4 weeks. During Weeks 4through 10, there were three telephone “visits” (at Week 6, Week 8, andWeek 10) to titrate dose, if necessary. However, dose titration wasallowed throughout the trial.

All subjects completed a 7-point blood glucose profile on any 3 daysduring the week immediately preceding each visit from Week 0 to Week 52.The 7 time points included samples from before breakfast and 2 hoursafter breakfast, before the mid-day meal and 2 hours after the mid-daymeal, before the evening meal and 2 hours after the evening meal and atbedtime (7 time points a day, over 3 days). These blood glucose (BG)values were recorded in the HBGM diary that was collected at clinicvisits. The diaries for Weeks 4 through 10 (during dose titration) whichwere discussed over the telephone were collected at the next officevisits.

A meal challenge test was performed at Week 4 (during dose titration),Week 26, and Week 52. Meal challenge venous blood sampling times were:−30, 0, 30, 60, 90, 105, 120, 180, 240, 300, and 360 minutes. Bloodglucose (BG) was also measured using HBGM glucose meters to aid theInvestigator in treatment decisions and values were obtained at −30, 0,60, and 120 minutes during the meal challenge.

Treatments for glycemic control used in the trial were the following:prandial insulin-FDKP (TI) inhalation powder, prandial insulin aspart,and basal insulin glargine. Subjects assigned to the TI InhalationPowder group (TI Inhalation Powder in combination with basal insulintherapy) received sc basal insulin glargine (LANTUS®) once daily (atbedtime) and inhaled TI Inhalation Powder 3 to 4 times a day,immediately before main meals or a snack as based upon clinical need.Adjustment of the TI Inhalation Powder dose and frequency of use togreater than 3 times a day was at the discretion of the Investigator.Subjects in the comparator group received SC basal insulin glargine oncedaily (at bedtime) and SC injection of rapid acting insulin (NOVOLOG®) 3to 4 times per day, immediately before main meals (no later than 10minutes before meals).

The primary objective of this trial was to compare the efficacy over 52weeks of TI Inhalation Powder+basal insulin versus insulin aspart+basalinsulin as assessed by change from baseline in HbA1c (%). A total of 565subjects were studied in sites in the United States, Europe, Russia, andLatin America. A total of 293 subjects received TI InhalationPowder+basal insulin, and 272 subjects received insulin aspart+basalinsulin.

The primary efficacy endpoint was assessed using pre-specified ANCOVAand Mixed Model with Repeated Measures (MMRM) analyses. Due todisproportionate dropouts between the TI Inhalation Powder+basal insulintreatment arm and the insulin aspart+basal insulin treatment arm, theassumption of missing completely at random for the ANCOVA model wasviolated. As such, the MMRM was used as a secondary confirmation. TIInhalation Powder met the primary endpoint of non-inferiority in theMMRM model, although not in the ANCOVA model. The mean change frombaseline over 52 weeks was comparable in both treatment groups, with aLeast Square Means treatment difference of −0.25% in favor of insulinaspart. Based on results from both models, there was not a clinicallysignificant difference between treatment groups in mean change frombaseline in HbA1c. Indeed, a comparable percentage of subjects reachedHbA1c target levels in the 2 treatment groups. There were nostatistically significant differences in the percentage of subjectswhose HbA1c level decreased to 8.0% (50.99% for the TI Inhalation Powdergroup, 56.16% for the comparator group); 7.0% (16.34%, TI InhalationPowder group; 15.98%, comparator group); and 6.5% (7.43%, TI InhalationPowder group; 7.31%, comparator group).

The reduction in HbA1c was comparable between groups and sustained over52 weeks. Subjects in the TI arm dropped to 8.21 (SD 1.15) % at Week 14from a baseline of 8.41 (SD 0.92) %; the reduction was maintained atWeek 52 (8.20 [SD 1.22]%). Subjects in the insulin aspart arm dropped to8.07 (SD 1.09) % at Week 14 from a baseline of 8.48 (SD 0.97) %; thereduction was maintained at Week 52 (7.99 [SD 1.07]%).

When the analysis of the change from baseline in HbA1c was corrected forthe last 3 months of insulin glargine exposure in an ANCOVA model, noeffect due to glargine exposure was found.

Over the 52-week treatment period, fasting plasma glucose (FPG) levelsdecreased significantly (p=0.0012) in the TI Inhalation Powder groupcompared to FPG levels in subjects using insulin aspart, despite similardose levels of basal insulin in both groups at both start and end pointsof the trial. In the TI Inhalation Powder group, mean FPG decreased 44.9(SD 104.7) mg/dL from 187.6 (SD 85.1) mg/dL at baseline to 140.1 (SD72.1) mg/dL at the end of the treatment period, compared to a smallerdrop of 23.4 (SD 103.1) mg/dL from 180.8 (SD 86.9) mg/dL at baseline to161.3 (SD 68.2) mg/dL over the same period in the comparator group.

A secondary efficacy endpoint was the percentage of subjects with a2-hour postprandial plasma glucose (PPG)<140 mg/dL and <180 mg/dL aftera meal challenge. Subjects with 2-hour PPG values in both categorieswere comparable in each treatment group at Weeks 26 and 52. Absolutevalues for PPG C_(max) at Baseline and Week 52 were the same in bothtreatment groups.

Subjects in the TI Inhalation Powder group lost an average of 0.5 kgover the 52-week treatment period compared to an average gain of 1.4 kgobserved in the comparator group. The difference between groups wasstatistically significant (p<0.0001) with a treatment difference of −1.8kg. The mean change from Baseline (Week 0) in body weight was notstatistically significant for the TI arm (p=0.1102), while the mean bodyweight gain for the insulin aspart arm was significant (p<0.0001).

Overall, comparable levels of HbA1c and postprandial blood glucoselevels were achieved in both arms of the trial; however TI InhalationPowder-treated subjects did so in the context of weight neutrality andwith more effective control of fasting blood glucose.

TI Inhalation Powder was well-tolerated over 52 weeks of treatment. Thesafety profile of TI Inhalation Powder was similar to that observed inearlier trials in the TI Inhalation Powder clinical development program;no safety signals emerged over the course of the trial. No pulmonaryneoplasms were reported. There was no statistical difference between TIInhalation Powder treatment and comparator with respect to change frombaseline in FEV₁ (forced expiratory volume in one second), FVC (forcedvital capacity), and TLC (total lung capacity). The most common adverseevents in the trial in TI Inhalation Powder-treated subjects were mildto moderate hypoglycemia and transient, mild, non-productive cough.

Seven-point BG profiles were derived from HBGM; data collected at allspecified time points are presented in FIG. 12 for the ITT and PPPopulations, respectively. No inferential statistics were performed.

FIG. 12 presents the 7-point BG profile at Week 52 for both treatmentarms. Pre-breakfast baseline values were lower in the TI arm as expectedfrom the Week 52 FPG values: 139.1 (SD 72.6) mg/dL for the TI arm vs.49.5 (SD 80.2) mg/dL for the aspart arm. From pre-breakfast topre-lunch, BG values were lower in the TI arm. However, from post-lunchthrough bedtime, mean daily BG values were similar in both treatmentgroups. Concordant results were observed in the PP Population (data notshown). There was a parallel and steady increase in BG from pre-dinnerto bedtime in both treatment arms that was likely a result of thesuboptimal dosing with insulin glargine. Bedtime dosing with insulinglargine may not provide full 24-hour coverage in all subjects with type1 diabetes (Barnett A. Vascular Health and Risk Management 2:59-67,2006) (LANTUS® was administered once daily by label). Although there wasa rise in underlying baseline blood glucose in both treatment arms bothin the evening and throughout the day the effect is more pronounced inthe TI treatment arm.

Example 3 A Prospective, Multi-Center, Open-Label, Randomized,Controlled Clinical Trial Comparing the Efficacy and Safety in Subjectswith T2 DM Receiving SC Basal Insulin and Prandial Inhalation of TI Vs.SC Premixed Insulin Therapy Over a 52-Week Treatment Period and 4-WkFollow-Up

This trial compared the efficacy as expressed by change in HbA1c over a52-week period of prandial administration of TI Inhalation Powder incombination with basal insulin therapy (TI group) versus a premix ofintermediate-acting and rapid-acting insulin (comparator group) insubjects with suboptimally controlled type 2 diabetes, previouslytreated with regimens of sc insulins±oral anti-hyperglycemic agents. Thereduction in HbA1c was comparable between TI+basal insulin and premixedinsulin. The percent of responders for an end of study HbA1c ≤7.0% wascomparable and not statistically different between the TI+basal insulinand premixed insulin groups. Notably fasting blood glucose was reducedsignificantly by treatment with TI+basal insulin as compared to premixedinsulin (see FIG. 13) Additionally both fasting blood glucose andglucose excursions were reduced for the TI+basal insulin group betweenthe beginning and end of the treatment period (See FIG. 14). As noted inExample 2 baseline blood glucose levels trended upward over the courseof the day for TI+basal insulin (see FIG. 14).

Example 4

This study was a phase 3, 24-week, open-label trial designed to evaluatethe efficacy and safety of prandial TECHNOSPHERE®/Insulin (insulin-FDKP,TI) alone or in combination with metformin versus metformin and asecretagogue, a current standard of care regimen, in subjects with type2 diabetes mellitus sub-optimally controlled on combination metforminand secretagogue. FIGS. 15 and 16 depict the trial design of theclinical study and the baseline demographics of patients enrolled in thestudy. Subjects were randomized 1:1:1 to one of the 3 treatment groupsand received anti-diabetic treatment based on their randomization groupfor the first 12 weeks; the subsequent 12 weeks of the trial wereconsidered an observational period.

The trial design was unusual in that there was not a formal run-inperiod to titrate study medications. Subjects had a total of only 12weeks of treatment to titrate to an effective dose of study medicationbefore an assessment of the primary efficacy endpoint was conducted.Subjects with continued sub-optimal control after 12 weeks of therapy,in any of the 3 treatment groups, were required to either switch toTI+metformin or discontinue participation in the trial. The totalduration of the treatment period was 24 weeks.

This was not a treat-to-target trial and investigators were not given aspecific HbA1c or fasting plasma glucose (FPG) goal to treat to.Investigators were allowed to titrate TI at their clinical discretionwith upper limits specified for preprandial, postprandial, and bedtimeblood glucose, but without a fixed dose schedule. Although the protocolallowed titration of up to 90 U TI per meal, the mean per meal dose ofTI was ˜65 U at trial endpoint, suggesting that investigators may havebeen reluctant to titrate upward.

In a head-to-head comparison of prandial TI alone or in combination withmetformin vs. a commonly used antihyperglycemic regimen. All threetreatment groups showed statistically and clinically significantreductions in HbA1c levels over the course of the study. TI wascomparable with respect to HbA1c and FPG reduction and significantlymore effective with respect to postprandial control—both in formal mealchallenges and in self monitored glucose profiles. Subjects treated withprandial TI alone or in combination with metformin over 24 weeks hadmean weight loss. The ultrarapid pharmacokinetics of TI may synchronizeinsulin levels with the post-meal rise in blood glucose, therebypreventing over-insulinization and concomitant weight gain.

TI alone or in combination with metformin was well-tolerated over 24weeks of treatment. FIGS. 17-28 depict the results of the study. Thesafety profile of TI was similar to that observed in earlier trials inthe TI clinical development program; no safety signals emerged over thecourse of the trial. Very low rates of severe hypoglycemia were observedin all treatment groups with no cases occurring in patients treated withTI alone or with oral hypoglycemics and in 2% of patients when TI andmetformin were combined. Even with such marked reductions in HbA1coverall, no increases in weight were seen. Detailed assessment ofpulmonary safety including FEv1 and DLCO over the 24 weeks of the studyshowed no difference in pulmonary function between patients inhaling TIand those on oral therapy alone.

TI+Metformin

For those subjects that completed the trial, prandial TI+metforminprovided a clinically significant mean reduction from baseline in HbA1c(−1.68 [1.0]%) after 24 weeks of treatment, comparable to that of astandard anti-hyperglycemic regimen. However, TI+metformin providedstatistically superior postprandial control compared tometformin+secretagogue after 12 and 24 weeks of treatment and acomparable mean reduction from baseline in FPG after 24 weeks. There wasmean weight loss (−0.75 kg) over 24 weeks in this treatment group and anoverall incidence of mild-to-moderate hypoglycemia of 35.0%.

TI Alone

For those subjects that completed the trial, prandial TI alone wassuccessful in providing a clinically significant mean reduction frombaseline in HbA1c (1.82 [1.1]%) after 24 weeks of treatment. The changefrom baseline was numerically superior to the standardanti-hyperglycemic regimen of metformin+secretagogue. At trial endpoint,TI alone provided significantly more effective postprandial control thancomparator with a comparable mean reduction from baseline in FPG. Therewas net weight loss (−0.04 kg) over 24 weeks in this treatment group andan overall incidence of mild-to-moderate hypoglycemia of 27.6%.

Metformin+Secretagogue

For those subjects that completed the trial, metformin+secretagogue wassuccessful in providing a clinically significant mean reduction frombaseline in HbA1c (1.23 [1.1]%) after 24 weeks, but with significantlyless effective postprandial control than the TI arms (FIGS. 17 and 18).The mean reduction from baseline in FPG and body weight was similar tothat observed for the TI+metformin arm (FIGS. 21-22). The overallincidence of mild-to-moderate hypoglycemia was 20.8%.

Prandial TI alone or in combination with metformin significantly lowersHbA1c levels over the course of 12 and 24 weeks (FIGS. 23-25). This isachieved by controlling blood glucose levels over a 24 hour period asdemonstrated by 7-point blood glucose levels. TI's main effect is byreducing post-prandial blood glucose excursion as evidenced byreductions in 1 and 2-hour post-prandial glucose levels, AUC and Cmax.The data from this trial support the use of prandial TI in combinationwith metformin in subjects with type 2 diabetes who require improvementsin both postprandial and FPG (FIGS. 26-28). They also indicate apotential for use of prandial TI as monotherapy in subjects with type 2diabetes who require an improvement in postprandial glycemic control butwho have adequate control with respect to FPG.

The majority of patients with type 2 diabetes will eventually requiretreatment with insulin in order to maintain glycemic control. Treatmentwith prandial TI alone or in combination with metformin provideseffective glycemic control with no weight gain. This is particularlyimportant for patients with type 2 diabetes who are often overweight orobese.

SUMMARY

The data demonstrate that TI alone or in combination with metforminclinically and significantly reduced HbA1c over 12 and 24 weeks withoutweight gain. TI alone or in combination with metformin controls overalldaily blood glucose levels better than metformin+secretagogue based on7-point blood glucose levels.

The data also demonstrate that TI alone or in combination with metformincontrols postprandial glucose excursions better thanmetformin+secretagogue (1) at 1-hr and 2-hr in meal challenge tests; (2)AUC levels at 12 and 24 weeks; (3) 1-hr and 2-hr postprandial glucoselevels (≤180 mg/dL) at 12 and/or 24 weeks; and (4) 1-hr and 2-hrpostprandial glucose levels (≤140 mg/dL) at 12 and/or 24 weeks.

In addition, TI alone or in combination with metformin lowers fastingblood glucose at 12 and 24 weeks.

Overall, incidence of hypoglycemia was low in all treatment groups.

Moreover, mean changes from baseline in lung function tests includingFEV1, FVC, TLC and DLco-HB1 for the TI alone and TI+metformin groupswere not significantly different from the metformin+secretagogue groupat week 12 or week 24

Unless otherwise indicated, all numbers expressing quantities ofingredients, properties such as molecular weight, reaction conditions,and so forth used in the specification and claims are to be understoodas being modified in all instances by the term “about.” Accordingly,unless indicated to the contrary, the numerical parameters set forth inthe following specification and attached claims are approximations thatmay vary depending upon the desired properties sought to be obtained bythe present invention. At the very least, and not as an attempt to limitthe application of the doctrine of equivalents to the scope of theclaims, each numerical parameter should at least be construed in lightof the number of reported significant digits and by applying ordinaryrounding techniques. Notwithstanding that the numerical ranges andparameters setting forth the broad scope of the invention areapproximations, the numerical values set forth in the specific examplesare reported as precisely as possible. Any numerical value, however,inherently contains certain errors necessarily resulting from thestandard deviation found in their respective testing measurements.

The terms “a” and “an” and “the” and similar references used in thecontext of describing the invention (especially in the context of thefollowing claims) are to be construed to cover both the singular and theplural, unless otherwise indicated herein or clearly contradicted bycontext. Recitation of ranges of values herein is merely intended toserve as a shorthand method of referring individually to each separatevalue falling within the range. Unless otherwise indicated herein, eachindividual value is incorporated into the specification as if it wereindividually recited herein. All methods described herein can beperformed in any suitable order unless otherwise indicated herein orotherwise clearly contradicted by context. The use of any and allexamples, or exemplary language (e.g. “such as”) provided herein isintended merely to better illuminate the invention and does not pose alimitation on the scope of the invention otherwise claimed. No languagein the specification should be construed as indicating any non-claimedelement essential to the practice of the invention.

Groupings of alternative elements or embodiments of the inventiondisclosed herein are not to be construed as limitations. Each groupmember may be referred to and claimed individually or in any combinationwith other members of the group or other elements found herein. It isanticipated that one or more members of a group may be included in, ordeleted from, a group for reasons of convenience and/or patentability.When any such inclusion or deletion occurs, the specification is hereindeemed to contain the group as modified thus fulfilling the writtendescription of any and all Markush groups used in the appended claims.

Preferred embodiments of this invention are described herein, includingthe best mode known to the inventors for carrying out the invention. Ofcourse, variations on those preferred embodiments will become apparentto those of ordinary skill in the art upon reading the foregoingdescription. The inventors expect skilled artisans to employ suchvariations as appropriate, and the inventors intend for the invention tobe practiced otherwise than specifically described herein. Accordingly,this invention includes all modifications and equivalents of the subjectmatter recited in the claims appended hereto as permitted by applicablelaw. Moreover, any combination of the above-described elements in allpossible variations thereof is encompassed by the invention unlessotherwise indicated herein or otherwise clearly contradicted by context.

Specific embodiments disclosed herein may be further limited in theclaims using consisting of or consisting essentially of language. Whenused in the claims, whether as filed or added per amendment, thetransition term “consisting of” excludes any element, step, oringredient not specified in the claims. The transition term “consistingessentially of” limits the scope of a claim to the specified materialsor steps and those that do not materially affect the basic and novelcharacteristic(s). Embodiments of the invention so claimed areinherently or expressly described and enabled herein.

Furthermore, references have been made to patents and printedpublications throughout this specification. Each of the above citedreferences and printed publications are herein individually incorporatedby reference in their entirety.

In closing, it is to be understood that the embodiments of the inventiondisclosed herein are illustrative of the principles of the presentinvention. Other modifications that may be employed are within the scopeof the invention. Thus, by way of example, but not of limitation,alternative configurations of the present invention may be utilized inaccordance with the teachings herein. Accordingly, the present inventionis not limited to that precisely as shown and described.

What is claimed is:
 1. A method of treating hyperglycemia in a patientwith diabetes, comprising administering to said patient in need thereofand having a hemoglobin A1C level ≥6.0% a combination of an ultrarapidacting insulin and a long acting insulin analog, wherein the ultrarapidinsulin comprises a dose comprising one or more cartridges of up to 32units of said ultrarapid insulin formulation administered at mealtime byoral inhalation, and a first dose of the long-acting insulin analog isadministered within 6 hours of waking, and optionally, administering asecond dose of the long acting insulin at 8 to 14 hours after said firstdose of the long-acting insulin, wherein said method further comprisesdetermining the ultrarapid insulin dose for a carbohydrate meal contentand administering a predetermined dosage of the ultrarapid actinginsulin formulation at mealtime for each daily meal.
 2. The method ofclaim 1, wherein the long acting insulin analog is administered within 3hours of waking in the morning.
 3. The method of claim 1, wherein thelong acting insulin analog is insulin detemir or insulin glargine. 4.The method of claim 1, wherein the long acting insulin is insulinglargine.
 5. The method of claim 1, wherein the ultrarapid actinginsulin comprises a dry powder formulation comprising recombinant humaninsulin and a 3,6-di(fumaryl-4-aminobutyl)-2,5-diketopiperazine.
 6. Themethod of claim 1, wherein the ultrarapid acting insulin comprisescrystalline microparticles of the recombinant insulin and the a3,6-di(fumaryl-4-aminobutyl)-2,5-diketopiperazine.
 7. The method ofclaim 1, wherein the ultrarapid acting insulin is administered using adry powder inhaler.
 8. The method of claim 1, wherein the hyperglycemiais resultant of diabetes type
 2. 9. The method of claim 1, wherein saidcarbohydrate meal content is ≥25%, to ≤200% of a usual meal content asused in determination of the predetermined dose.
 10. The method of claim1, wherein the ultrarapid acting insulin formulation is insulin-FDKP.11. A method of treating hyperglycemia in a patient in need thereof witha combination of an inhalable ultrarapid acting insulin and an exogenousbasal insulin comprising administering the inhalable ultrarapid insulinwith a meal, and continuously infusing a short acting insulin with aninsulin pump throughout the day.
 12. The method of claim 11, wherein theshort-acting insulin is a recombinant human insulin or a rapid actinginsulin analog.